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SAN JOAQUIN LOCAL HEALTH- DIS RIOT <br /> FOR OFFICE USE: 1601 E-.• Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 C- /6/° <br /> THIS PERMIT EXPIRES 1 YEAR' FROM DATE ISSUED Date Issued 6-1,1-76 # <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 Ru and .Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCA () D/ w <br /> CENSUS TRACT <br /> Owne'r's Name / Y Phonet��4 6 <br /> Address <br /> City <br /> Contractor's Name License <br /> TYPE OF �, ...�.�, �-�-- <br /> WORK (Check) • NEW WELT, �/-7 DEEPEN / / PRECONDITION_/�/ DESTRUCTION/�J _ <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT S/ <br /> ► Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY M <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation - X-J., <br /> Domestic/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 ' u <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. C <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 completion of my work on a new well, I will furnish the San Joaquin Local Health District a !1 <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 INSPE <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE } <br /> (DRAW PT�L PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I " . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ' � 7 6 �-n -moi � � �, zr�•!/r <br /> E H 1426 Rev. 1-74 Oak (�' �`� v d ' 76 <br />