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w 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. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 11;3 -;7;7 <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 . .4I Al. CENSUS TRACT <br /> Owner's Name �44 Z49 Phone <br /> Address U141il City <br /> Contractor's Name Q `] License 1 '� Phone&JI,$Z_L� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION j / DESTRUCTIONS <br /> PUMP INSTALLATION /jam/ PUMP REPAIR / / PUMP REPLACEME /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK df- SEWER LINESPIT 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 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 : 'pr <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approxima e Depth (f <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 __ TITLE 4MJ-74/l%J <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY 1� 7 77 <br /> APPLICATION ACCEPTED BY - DATE fi f <br /> ADDITIONAL COMMENTS: 10/ <br /> PHA II GR UT INSPECTION PHASEi I/FINAL INSPECTION <br /> INSPECTION BY DATE jl INSPECTION BY DATE <br /> ILI <br /> 50 �Vw <br /> E H 1426 Rev. - I-74 6 77 _ 2 <br />