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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -Los fOFFLCE USE: 1601 E. Hazelton Ave:; Stockton, Calif. <br /> ij Telephone: ` (209)_466.-76781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76r/j- f <br /> Ij .fir" c lip <br /> THIS.-PERMIT ..EXPIRESI1.YEAR-FROM•DATE ISSUED Date Issued /-,47 <br /> w „ (Complete In. Triplicate)'.. <br /> Application is hereby made to the San Joaquin Local HealthiDistrict for a permit to construct <br /> and/or,_ins tall. the work herein described. ;This applicationP-is Cade 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/LO TION -L� - 4-ir-C '• CENSUS TRACT _ <br /> . <br /> i r. ei� r Kai �7T' k <br /> 3EA <br /> � <br /> Owner s Name Phone <br /> ' `G.tJ - - - <br /> Address - __..w-... . City <br /> ' 2 <br /> Contractor Name License #;Mem , Phone <br /> II <br /> TYPE OF-WORK (Check) : NEW WELL 1-7 DEEPEN '/7 RECONDITION /? DESTRUCTION /rT 17 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> — <br /> Other / / TTT EM <br /> k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> JLSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> J PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domdstic/private Drilled Dia;;-of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection -Rotary Type of Grout <br /> Disiosal Other _ Other Information <br /> Geophysical. Surface Seal. Installed B : <br /> PUMP INSTALLATION: Contractor <br /> k L Type of Pump R.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: <br /> /7 State Work Done ­ <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> .1 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District , <br /> and the State of California pertaining to or' regulatinp, 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-the -well in.use.. The above <br /> i <br /> information is true to the-best of my knowledge -and belief. I WILL CALJ6, F A'GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL INSP CTION. TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SI XE <br /> FOR DEPARTMENT USE ONLY <br /> ` PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> II PHASE II GROUT INSPECTION PHAS I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - 2-lam-7 <br /> E H 1426 . Rev. 1-74 <br />