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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 /> TITS PERMIT EXPIRES 1 YEAR `ROM DATE ISSUED Date Issued <br /> � `! {Complete In Triplicate) <br /> Application is hereby made the Sun 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 Joaquit <br /> County Ordinance No. 1862 Arid the Rules d Re ulati n <br /> of the San Joaquin Local Health District. <br /> p 6S Z -3f� fJZN <br /> JOB ADDRESS/LOCATION I S. .c'� �e %R �(CENSUS TRACT <br /> :t AA <br /> Owner's Name k--_Q. 'lae, o�cA O Phone $23- $S' <br /> Address 23 City Ina:�'(-� � a <br /> Contractor'a Name •A) S a,�� 1� . a,.c n _, License # 2. Phone off 3 z13" <br /> t TYPE OF WORK (Check)-. NEW WELL /� DEEPEN '/7 RECONDITION /? DESTRUCTION /� <br /> r PUMP :INSTALLATION . PUMP REPAIR /� PUMP REPLACEMENT <br /> Othe / / . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (n <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 °1 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 F' Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A) + <br /> Type't.of Pump `1 H.P. 25 - <br /> PUMP REPLACEMENT: / -State Work Done <br /> PUMP. .REPAIR: / / State Work Done <br /> p <br /> DESiTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> F 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 /> tPRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY J DATE -�7 <br /> ADDITIONAL COMMENTS: i <br /> i <br /> PHASE,)11 GROUT INSPECTION PHASE IofINAL TXSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE �;4-7-76 <br /> ­-,E,,H 1426 Rev. 1-74- r' W75 2M <br />