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V4f6 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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f ,g-76' <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 p`5r7� CENSUS TRACT <br /> Owner's Name -9l,+IVG Phone <br /> AddressIns- City <br /> Contractor's Name SA License # Phone ' <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN '/ / RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT I7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY L; <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 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 BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter tAS� �G �`T USS Approximate Depth IYw�r AAA <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Lo al 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 T ANT—A FINAL INSPECTION. Hwy VF19A— <br /> SIGNE �����6 TITLE <br /> „ DRAW POT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r (� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROSPIFIC N PHASE III/FINAL IN ECTION <br /> INSPECTION BY DA INSPECTION BY ATE a 317l <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />