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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> JFFICE 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 l YEAR FROM DATE ISSUED Date Issued <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 S�� ,, ri. 'Z„y 0/e.A/• CENSUS TRACT <br /> 3`335. <br /> Owner's Name j o -y i '° Phone <br /> Address i_� X-� � td� � City ,rc� _ <br /> Contractor's Name Ogg d g °gf [ ,�,�� t. rr�j License #jyfG Phone ` <br /> i <br /> TYPE OF WORK (Check) : NEW WELL%/ DEEPEN / / RECONDITION /4/ DESTRUCTION /� ~ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKI SEWER LINES PIT PRIVY V <br /> SEWAGE DISPOSIELD CESSPOOL/SEEPAGE PIT /Gid` OTHER <br /> PROPERTY LINE - PRIVATE _DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial Cable Tool Dia, of Well Excavation = / 2 <br /> 4t::f 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 Rotary Type of Grout '• <br /> Disposal Other Other Information 4 <br /> Geophysical Surface Seal Installed By: C.a�sr <br /> t� <br /> PUMP INSTALLATION: Contractor N2veer ,�� <br /> g; Type of".Pump 5 ': H.P, <br /> PUMP REPLACEMENT: <br /> � /_/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well! Diameters 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 Californ:ialpertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 TITLE , ..� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 07 <br /> z <br /> ---FOR DEPARTMENT• USE-ONLY - --- ---^--~� - -y <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL-COMMENTS.: <br /> PHASE IV-GROUT, INSPEC.TO PHAS I;U/VAAL INSPECV10 <br /> INSPECTION BY F: DATE INSPECTION .BY DATE 5/77 <br /> 914111- .tee <br /> 2M <br /> 0477 <br /> 4 E 1426 Rev. = 1-74 <br /> _ Y <br />