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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r / THIS PERMIT EXPIRES 1 YEAR 'FROM DATE ISSUED Date Issued _Z-4j-?Z <br /> (Complete In Triplicate) <br /> Applicdti6n is hereby made to the San Joaquin Local Health District for a. permit to construct <br /> and/or4install the work herein described. This application is made in compliance with Sen Joaquin <br /> County <[Ordinance No. 1862 and the Rules and Regulations of .the San. Joaquin Local.,Health District. <br /> JOB ADDRESS/LOCATION CEISUS TRACT. . <br /> Owner's" Name L Phone`.j< <br /> Address' 77. — city <br /> Contractor's Name �141_ . .. . ..Woo iQ �,2a(_(_j jJ�'License rZ � .- <br /> i ,hone r: 2— <br /> iC <br /> TYPE Ot WORK (Check) : NEW WELL/7 DEEPENILT—RECONDITION 17 DESTRUCTION J7 <br /> PUMP INSTLATION �J'/—/—PUMP REPAIR -/-7—PUMP LAC / f <br /> Other <br /> /%AL �y <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE.- PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialable Tool Dia. of Well Excavation -,Z 27 / V <br /> Domestic/private Drilled Dia. of Well Casing a \ <br /> Domestic/public . Driven Gauge of Casing <br /> , igation '� _w.___�_ .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. i <br /> PUMP REPLACEMENT: . / / State Work Done <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 cimpletion 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 <br /> (DRAW PLOT PLAN ON_REVERSE SIDE <br /> PHASE I , <br /> XFOR DEPARTMENT USE ONLY - - — <br /> _ . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> a i PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /- -77 <br /> E H ].426Rev. 1-74 a X75 2M <br /> r <br />