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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> YO-R,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 -/7-76 <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 / 2 2 7 CENSUS TRACT <br /> Owner's Name . ` - 3� �� Phone <br /> Address / `7`7 `7 /1 vim- Ok- City221, <br /> Z--Irs04 <br /> �., <br /> Contractor's Name ' �°''� License Phone S4L'-)Y77 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7' RECONDITION f7 DESTRUCTION (7 <br /> PUMP INSTALLATION L� PUMP REPAIR /-7 PUMP REPLACEMENT %J <br /> Other L-T <br /> DISTANCE TO NEAREST: SEPTIC TANK 41j 6 SEWER LINES r'. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CES 0/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC STIC WELL (,v <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 �Z <br /> Irrigation Gravel Pack Depth of Grout Seal `o ' <br /> Cathodic Protection Rotary Type of Grout CIEHFICT <br /> Disposal Other �_ Other Information <br /> Geophysical Surface Seal Installed BY !�:ZARK <br /> PUMP INSTALLATION; Contractor <br /> PIMP �>' oTEfF-ft " <br /> Type of Pump H.P. <br /> PUMP 'PLACEMENT: j//- State Work Done ' <br /> PUMP '.REPAIR: L7 State Work Done <br /> ,?ES=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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F NAL IN PECTION. <br /> SIGNED , . r l— TITLE <br /> KDRAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT YCTFC; DATE �7�7t <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE z ( INSPECTION BY DATE o /J <br /> E H 1426 Rev. 1-74 1-74 ZM <br />