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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FO$rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -1,5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedl <br /> (Complete In Triplicate) Zo( ._ C`eO -v-7 <br /> Application is hereby made to the San Joaquin Local Health Diattict for a permit ta.construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and.,theTRules and-Regulations of 'the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �F y _ 1 CENSUS TRACT <br /> Owner's Name Phone 7�• .2.? <br /> Address J7�� '�.cr�Gc a, — City S� <br /> F Contractor's Name License # �� Phone K-2-1-5- <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN '/7 RECONDITION I7 DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR /-7 PUMP REPLACEMENT /7 *- <br /> Other / 1 <br /> i <br /> G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' 6' <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 s <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other L Other Infoimation <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <4 <br /> Type of Pump ^ H.P. <br /> PUMP 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-'REPORT76f ifie well and notify them before putting the..well in use. The above <br /> information is true to the-best-of my knowledge and belief. 1--WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO jrKUTING AND A.FINAL INSPECTION.. <br /> SIGNED s TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,L DATE 4 �7 5 <br /> ADDITIONAL COMMENTS: <br /> PEASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> 4 INSPECTION BY DATE INSPECTION B r DATE f <br /> ri E H 1426 Rev. 1-74 1-74 2M <br />