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Cam 0+��*� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOIA SOF SCE USE-. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 975' <br /> (Complete In Triplicate) 7-o O zo- 2-:3 <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 f 1 <br /> ���.. �� CENSUS TRACT <br /> Owner P s Name 0" ., Y.-P m Phone <br /> Address D 113 G S 94.,r City <br /> Contractor's Name License # Lft2ldnhone (74 <br /> 407 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_7 RECONDITION /? <br /> Other / f DESTRUCTION <br /> PUMP INSTALLATION /_/ PUMP REPAIR _77 PUMP REPLACEMENT /7 <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 Cable Tool Dia, of Well Excavation <br /> Domestic/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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .` H.P. r O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PM -REPAIR: State Work Done 2 G � <br /> ✓ ,fit <br /> E&TRUCTION 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 w dCea belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR NG AND A FIN INS ION. <br /> SIGNS V <br /> ITLE , <br /> PLOT PLAN ON RNERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPUTION PHASF, I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY NDATE <br /> E H 1426 Rev. 1--74 1-74 2M <br />