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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USIE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /yam-2 <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 work1herein described. This application is 'made in compliance with San Joaquin <br /> I County Ordinance No. 1862 and the Rules and Regulations of the -San Joaquin Local Health District. <br /> E JOB ADDRESS/LOCATION <br /> ) �( a,;11,111_J-e,rl f @1 OL&.Ad CENSUS TRACT <br /> Owner's Name <br /> Address I� w City . <br /> Contractor's Name License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/_/ RECONDITION / / DESTRUCTION /_7 <br /> I PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br />" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 12001 <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 /> t Domestic/private Drilled Dia. of Well CasingAl <br /> Dri-ven.= <br /> 7 Irrigation 7 Gravel Pack Depth of Grout Seal -- <br /> Cathodic Protection /� Rotary Type of Grout -- <br /> Disposal Other Other Information — G <br /> i <br /> Geophysical Surface Seal Installed BY: <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: - / State Work Done <br /> PVMP...RE-PAIR: , t <br /> / /---State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> gl,�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 /> alter completion of mywork on a new well, I will furnish the San Joaquin Local Health District a <br /> FELL 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 GR TING AND A1;FjNAL IN ECTIO . <br /> k SIGNED ITLE . + <br /> (DRAW-1PLIOT PLAN ON RE Y19E SIDE) „ <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE e <br /> ADDITIONAL COMMENTS: 11 <br /> PHASE II GROUT INSPECTION PHAS II 1N4 INSPECTI N <br /> INSPECTION BY AAIL i DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 o <br />