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SAN JOAQUIN LOCAL HEALTH DISTRICT Gl <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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10--477 <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 ,, 4j?015 2:� dam, fie, CENSUS TRACT <br /> Owner's Name 1Ld A" TR� �� � Phone <br /> Address City dl,/ <br /> Contractor's Name UAZ, CJo ja,[ � �i o,�_ License #24 `76 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_7AL <br /> PUMP INSTLATION /—/ PUMP REPAIR / PUMP REPLACEMENT /_7Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY - <br /> SEWAGE <br /> RIVY SEWAGE DISPOSAL, FIELD CESSPOOL/SZEPAGE PIT OTHER <br /> PROPERTY .LINE PRIVATE DOMESTIC--WET ` PUBLI,�._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 /> L.--Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of ,,Grout <br /> Disposal Other Other 2nformatio_n <br /> Geophysical Surface 'Seal Installed By: <br /> PUMP INSTALLATION: Contractor' <br /> Type of Pump :. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done e 7`e.,,y P-0 baca! <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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 2z— <br /> TITLE,�_!c . <br /> _ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE lQ z g2? <br /> ADDITIONAL COMMENTS: C 17 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �1, %, DATE <br /> 6/77 _ 2M <br /> E H 1426. Rev. - 1-74 , <br />