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A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U E: 1601 E. Hazelton Ave_;�.o.AStockton, Calif. �. <br /> - Telephone : x(209) 466-6781 <br /> ` 114 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 23 r <br /> (Complete In Triplicate) <br /> Application is•..hereby:,,grade 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 Jo4q{lin , <br /> County Ordinance No. 1862 and .the Rules and Regulations of the San Joaquin Local Health District. <br /> tis'? N : t `�-2-s'o-. o <br /> JOB ADDRESS/LOCATION ,� QI CENSUS TRACT <br /> Own%er's Name Phone - <br /> / A <br /> Address City SZ C-/�ZGAf � <br /> Contractor's Name _ - License Phone S . <br /> TYPE OF WORK (Check) : NEW WELL Z -7 <br /> DEEPEN /_/ RECONDITION '/ / DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPL-ACEMENT /7 <br /> Other — 4 i <br /> DISTANCE TO NEAREST: SEPTIC TANK sF PIT PRIVY <br /> SEWAGE DISPOS4L FIELD -- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIME/.L5 t RIVATE DOMESTIC WELL� -(PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS s <br /> i <br /> Industrial Cable Tool Dia. of Well Excavation /2 ITX-� <br /> YDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection RotaryType of Grout <br /> Disposal OtherOther Information <br /> Geophysical Sur e to d BY: <br /> ..-7 -: q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / States 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 b st4t. 9y owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR A FIN P E 10 t N. <br /> SIGNED TITLE � - ` <br /> (DRAW PLOT PLAN ON REVERSE SIDE) Dt <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I } <br /> APPLICATION ACCEPTED BY ` DATE <br /> ADDITIONAL CO NT •,L ,y m / �� s �rr.7 !� <br /> -P S ROUT -INS'PECTION' "" u / NSP6TION // <br /> INSPECTION BY DATE_ - -:INSP."C `>�N B AT.E. < <br /> i�77 <br /> E H 1426 Rev.-1-74 -� 2M : <br />