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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. _2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -S-- 2 <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 � It V - CENSUS TRACT .P13 f2e Y 6 <br /> J ' .. � � � l <br /> Owner's Name G{1 ill K / Phone 41/ - <br /> j <br /> Address �Iv City �� <br /> Contractor s Name <br /> License #j�Q 7Q Phone <br /> �i <br /> TYPE OF WORK (Check) : NEW WELL AT DEEPEN / / RECONDITION /�/ � DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR I PUMPREPLACEMENTIT <br /> Other 1 ! e <br /> DISTANCE TO NEAREST: SEPTIC TANK t- SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL M2Y- PUBLIC DOMESTIC WELL �-/ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of-Well Excavation <br /> Domestic rivate Drilled Dia. of Well Casing <br /> mestic/p <br /> Driven Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal'Cathodic P!-1151-tio <br /> n _ Rotary Type of Grout <br /> D Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor G <br /> Type of Pump ' H.P. <br /> F yp .� <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> E k <br /> PUMP REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Wall Diameter <br /> 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 t e be t f my- knowledge and belief. x WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTI D A IN SPECT ` <br /> SIGNED TITLE <br /> DRAW <br /> PLAN 'ON RE E25E SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 2 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: - <br /> PRASE II G OUT INSPECTION PHASE III FINAL INSPECT N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> x E H 1426 Rev. '1-74 <br />