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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP, PERMIT Permit No. 6-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S6 <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..,: 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> IOONCENSUS TRACT <br /> Owner's Name A;49 Phone <br /> Address J / City <br /> Pei 1_) 9 <br /> Contractor's Name ?' /- License 1 `� Fhon <br /> TYPE-0FW0RK-(Check);: NEWeWFLLDEEP_EN- - RECONDITION/ tr DESTRiTCTION=/ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY EN <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC .WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 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 <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: F State Work Don <br /> P?�� <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 GROUTINGkAND A FINAL INSPECTION, <br /> SIGNED TITLE <br /> PLANT ON EWCRSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> . PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS C / <br /> PHASE II GROUT SPEC.G ON PHASE III DINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 7a-76' <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 . <br />