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�x SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOE OFFICE USE: 1601 9. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ilAc Elf APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. P6,5-4:,) <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -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 Q CENSUS TRACT <br /> ? Owner's Name - Phone ' <br /> Address �y0c�Z City C' d, <br /> 1 k � <br /> Contractor's Name t , a r► /z�J•V si License-4,PPhone� j� 3cQ� <br /> TYPE OF WORK (Check); NEW WELL -/R'DEEPEN 17 RECONDITION /7 DESTRUCTION ff <br /> PUMP INSTALLATION / UMP REPAIR '/-7 PUMP REPLACEMENT f 7 <br /> Other / / . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK gam_ SEWER LINES Zr ' PIT PRIVY <br /> ✓°4 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 ___AfC"able Tool, Dia. of Well Excavation <br /> _4,:fflomestic/private Drilled Dia. of Well Casing <br /> Domestic/publicJE <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protecty ion Rotary. Type of Grout <br /> i.- Disposal i Other Other Information <br /> Geophysical r � ;. Surface Seal Installed 'B <br /> l PUMP INSTALLATION:7—dontractor -�/''1. L L e,. A` <br /> Type .of Pump H.P. . <br /> f PUMP REPLACEMENT•" <br /> / /� State Work Done ' <br /> PUMP .REPAIR: / / State Work Done __r. _ . s <br /> r,. <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 /> f 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 Sanr 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 FINAL INSPE ION. 1 <br /> , SIGNED k TITLE <br /> (DRAW PLOT PLAN-ON REVERSE_S.IDE)._. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY ATE <br /> ; ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTION PHAS INSPECTION <br /> INSPECTION BY DATE -76 INSPECTION BY DATE o <br /> E H 1426 Rev. 1-74 h/75 2M.CO <br />