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y d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a=eFOS FF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. G/S3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , r -76 <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 0,te i /e ®PNGJ� o /��i�rK CENSUS TRACT <br /> Owner's Name :G , j' y _ CL rr-'J Phone <br /> Address F 9 S—b b"', ee :::InE� City o"- <br /> Contractor's Name a License # 193 7),X—Phone 475f 76 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /7 DESTRUCTION /_j <br /> PUMP INSTALLATIONL-7 ENT PUMP REPAIR PUMP REPLACEM /7 <br /> Other /-T <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 ` a '04'a, <br /> Type of Pump H.P. hflf <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: &? :State Work Done m, `X-A40 JO/'P(/" Nt- .§jam <br /> ggE RUCTION 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* knowled nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UT NG AND A FINAL INS ECPI . <br /> SIGNED ITLE _ <br /> �DM PLOT PLAN ON FMARSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 71 DATET <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />