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SAN JOAQU.IN LOCAL "HEALTH DISTRICT E <br /> FOR!OFFICE USE. 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: ''J(209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7LS= Ua <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued /_T- ,74` <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sen Joaquin Local Health District for a permit -to construct i <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .✓ CENSUS TRACT <br /> Owneres Name Phone.9y <br /> yxsO- <br /> Address Cit <br /> Contractor's Name Q� 77+ License hovel <br /> i <br /> i <br /> rf <br /> TYPE: OF WORK (Check): NEW WELL /? DEEPEN /7 RECONDITION /_' DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT / I <br /> O they " <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 /> Domestic/private Drilled 101 Dia. -of Well Casing � ! <br /> omestic/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 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: - I/T/ State Work Done <br /> ,RES;RUC` TION 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 FINAL INSPECTION. <br /> SIGNED rs G ! 7� ��� 1- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> _ FOR DEPARTMENT USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED BY DATE 1 L-7 5 <br /> ADDITIONAL_COMMENTS: . <br /> PHASE II GROUT INSPECTION PHASE ' 3 /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - .- <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />