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PIC <br /> k SAN JOA UIN LOCAL HEALTH <br /> Q DISTRICT <br /> FOR:OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. I <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DAT'E 'ISSUED Date_ Issued 76 <br /> J6 1 <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 /> .FOB A DRE�5 ���� i <br /> CENSUS TRACT <br /> Owner's Name Phone f <br /> Address .. <br /> City <br /> Contractor's Name <br /> "A� Licensephoney /. } <br /> TYPE OF WORK (Check): NEW WELL/� DEEPEN /7 RECONDITION F7 DESTRUCTION f'7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /=7 1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES6� PIT PRIVY <br /> SEWAGE DISPOSAL IELD /SEEPAGE PIT OTHER <br /> PROPERTY LINE4RIVATE DOMESTIC WEL PUBLI WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of .Casing <br /> irrigation Gravel Pack Depth of Grout Seal p <br /> Cathodic Protections Rotary Type of Grout <br /> Disposal '' Other Other Information <br /> Geophysical <br /> �. Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor *11CMA4 .5 4&L4,� <br /> s . <br /> Type .of Pump H.P. 3/ <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 <br /> WELL DRILLERS REPORT of the well and notif them before <br /> y putting..the..well. in-use.... The above <br /> information is true to the-best -of.-my. knowledge abelief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO / <br /> op <br /> SIGNED Eit�l ..+v <br /> PLOT FLAN ON REVERSE SIDE <br /> PHASE I FOR D. PARTM NT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 6 3 e17 1 <br /> ADDITIONAL COMMNTS_: <br /> hrz� d�! �p <br /> PHASE II GROUT INSPECTI PHASE/III/FIN N E ION <br /> INSPECTION BY DATE 9 3 INSPECTION BY. rDATE 1/ <br /> E H 1426 <br />