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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -f—or,-"OFFICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7"7- <br /> .THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,3;/Jf-7J <br /> G fF ,? ril - fo2c ,ej• (Complete In Triplicate) --5, / ^ /f'D /j <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 FAX a l/a { Sa r- �IW � CENSUS TRACT <br /> Owner's Name -r- A -, 5 Z Phone 7.S-g j yL C <br /> Address e ZZ e9 / / C - e7 A I- City <br /> Contractor's Name License q s' Phone,?�74 l ' ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /=jF--DEEPEN /CONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT 1-T <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 �. <br /> Industrial ale Tool Dia. of Well Excavation 6� <br /> c----ffo-me s tic/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 _ �� �$ ee if <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By, <br /> PUMP INSTALLATION: Contractor (f <br /> Type of Pump H.P. 3 <br /> UMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 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 the -well 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 GROJaING AND A FINAL INSPE <br /> SIGNED TITLE -[r�2.�r <br /> (DRAW PLOT PLAN `ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE � /6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 , 2m' <br />