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'r SAN JOAQUIN LOCAL HEALTH DISTRICT <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. ZZJIa_S-&) <br /> ,�( �/ , THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> `"'f 30 U (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 �CA 7,9 CENSUS TRACT <br /> Owner's Name „� �_ Phone <br /> Address 16 C/ ' City <br /> Contractor's Name 41e License af-.-�72-Phone 6; -V 93� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <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 /> is-Domestic/private /Drilled Dia, of Well Casing — <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal --�� <br /> Cathodic Protectiony- Rotary Type of Grout <br /> Disposal Other Other Information j <br /> Geophysical Surface Seal Installed By:hZel& Ve <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 GRO TING AND A F NAL INSPECTION. <br /> SIGNED TITLE <br /> (DKW PLOT PLAN ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �✓ DATE 2-12— :Z2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III_/FINAL INSPECTION <br /> INSPECTION BY DATE" / INSPECTION BY _� DATE •- 3 <br /> ��z�-..�� ��,�i�0 7 ? �✓/ 3/76 2M <br /> E H 1426 Rev. 1-74 <br />