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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOA.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: 7�-���/` <br /> p (209) 46b-67$l <br /> 3 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74— 6/2-W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 7- 76 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,, >: 1 CENSUS TRACT <br /> Owner P s Name � � ,.� 2C? ,2� Phone -7106, <br /> Address %J a;,. 'i � � _ City <br /> Contractor's Name , ' License hone <br /> TYPE OF WORK (Check): NEW WELL /DEEPEN /-7 RECONDITION /-7 DESTRUCTION -'? <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT / - <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 <br /> ndustrial able Tool Dia. of Well Excavation _ ? �J <br /> " Domestic/private Drilled Dia. of Well Casing t, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal `s <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: ry, <br /> PUMP INSTALLATION: Contractor „��, ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Appro_ imate Depth "'jp <br /> Descri a Material and Procedure <br /> I hereby agree to comply with all laws and Vegulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU3jNG ANDA,,FINAL INSPECT ON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Q DATE1,-7& <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY !'.�� DATE )olf <br /> E H 1426 Rev. 1-74 1-74 2M <br />