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RY <br /> U4 ' SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> FOF�7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP P T Permit No. 6-, Ze kJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE SSUED Date Issued 7,6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health D strict 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 ", , gl/l� ��J p �, <br /> tel_ oi ,rCGY - CENSUS TRACT <br /> Owner's Name -d ` Phone .SCJ - <br /> Address o�7f]/� �1 L,a, ��J City' <br /> Contractor's Name l License # � Phone <br /> J J <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION /� PUMP REPAIR/7 PUMP REPLACEMENT f-7 <br /> Other /� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> MEel t7 �a�1 <br /> PROPERTY LINE - PRIVATE DOSTIC WELL: PUBLIC STIC WELL ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation a pJ <br /> Domestic/private —�' Drilled Dia. of Well Casing �� V <br /> Domestic/public Driven Gauge of Casing 1W <br /> /, / Irrigation Al Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _6 Rotary Type of Grout <br /> —Disposal Other Other Information g i�oJlr 'a LJ <br /> Geophysical Surface Seal Installed Bv: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . State Work Done <br /> PM .REPAIR: L 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 G!RUING AND A FIUL INSPE ION. �N <br /> SIGNED TITLE (� <br /> gDRAR PIE PLAN -ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE - 76 <br /> ADDITIONAL COMMENTS <br /> PHASE 7 GROUT INSPECTION PHASE III/FIXAL INSPECTION <br /> INSPECTION BY A/ DATE INSPECTION B DATE - <br /> E H 1426 Rev. 1-74 U/° - 5 2M <br />