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OF_FICE USE: 1601 E SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� / <br /> Stockton Calif. (� <br /> Hazelton Ave. , <br /> Telephone: (209) 466-6781 ��� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> JAN 16 1978 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. <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 �$6,2..,,�nd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LO ATION <br /> t" CENSUS TRACT <br /> Owner's Name Phone -74,f- f1 d 6 9 <br /> Address - _ City <br /> r <br /> 01 <br /> Contractor s Name <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION _/ / PUMP REPAIR PUMP REPLACEMENT -7 <br /> Other / / _ C/1 <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 �! 1 0' , - -'�' <br /> Type of Pump / � H.P. <br /> -r-- <br /> PUMP REPLACEMENT: / / State Work Done 7 --®---- <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 mf knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OU G D A F AL INSPE ION. <br /> SIGNED -LTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - 1-74 - <br />