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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOP OFFICE USE: 1601 E. Hazelton Ave, , Stockton <br /> Calif. <br /> j Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> zz-��s P <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issuedr -7� <br /> (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to-`construct <br /> i 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/1/ 11 l <br /> CENSUS TRACT <br /> Owner's Name ` <br /> Phone <br /> Address 19 6 3 � -L <br /> , nn city <br /> Contractor's Name J49 <br /> # License Phone <br /> - 4 <br /> IL <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN ' <br /> RECONDITION DESTRUCTION / <br /> /_/ _7 <br /> _ - PUMP INSTALLATION / /' PUMP REPAIR/ / P <br /> Other 1/ / UMP REPLACEMENT y ; <br /> . - <br /> DISTANCE TO NEAREST: SEPTICTANKj <br /> SEWER.�LINES <br /> SEWAGE 'DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER �+ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTEPUBLIC DOMESTIC p <br /> NDED USE TYPE OF WELL C WELL 'U <br /> Indu_stri_al _ { CONSTRUCTION SPECIFICATIONS <br /> _ <br /> Cable Tool <br /> Dia. of We11 Excavation <br /> Domestic/private x~+ �Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation <br /> 1 Gravel Pack ' Depth of Grout Seal <br /> _ Cathodic Protection Rotary' Type of Grout <br /> Disposal Other ; Other Information <br /> -Geophysical . Surface Seal Installed $ <br /> PUMP INSTALLATION: • Contractor P <br /> 'Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: . / State Work Done _} <br /> PUMP .REPAIR: State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 weli •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..kn wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A F-INOL9 INSPE <br /> SIGNED 4- <br /> TITLE <br /> 1 RAW I'L T' PLAN ON REVERSE SIDE) -71 „ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: DATE -l�- <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 3/76 2M <br />