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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> t. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �I� 3 <br /> 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 '� Z4,2_ h/ - CENSUS TRACT <br /> Owner's Name rel/ oy Phone 44 <br /> Address A Irpry City <br /> Contractor's Name License # 6-5'Z Phone ke <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ZA2 ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD __.L£ti CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE OMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> __L_---Dome s tic/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 40 :CAk <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 5ROUTIN2 APM A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY L.�u.0 DATE 12 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE _III/FINAL INSPECTION <br /> INSPECTION BY f DATE /-To ',7�57' INSPECTION BY .NF1/ DATE f 'i e) <br /> E H 1426 Rev. - 1-74 �` 6/77 _ 2M <br />