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SAN JOAQ '� r�L HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haze. n Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �GG� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Is - <br /> 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 Rule and Reg lations of the San Joaquin Local Health District. <br /> _?, 826 f . <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ; joy��=�( / Phone <br /> Address ��/� �Cl /!�d dive'• City <br /> Contractor's Name ' e License �� 0�( Phone ?l <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK f319_ SEWER LINES — PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /06" CESSPOOL/SEEPAGE PIT 1 ;L OTHER <br /> PROPERTY LINE�P ;Z RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �• <br /> Industrial Cable Tool Dia. of Well Excavation _ & <br /> _L.1 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 _j Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B V&AzZ i7 <br /> PUMP INSTALLATION: Contractor <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 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 ANP A INAL I PE CT ION. '���` <br /> SIGNED R TITLE . <br /> !',(DUV PLOT PLAN ONW9RSE SIM) ' <br /> R DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROVf INSPECTION P /F NAL INSPECTI0 <br /> INSPECTION PY 3 ;• DATE INSPECTION BY DATE / <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />