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R <br /> 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. .7G-3_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM D TE ISSUED Date Issued L_22-244 <br /> (Complete In Triplic e) <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. 18/6_2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1.� ALl 'S;*P-1 � '� A GJ <br /> - - .... , _..._._.�.' CENSUS TRACT JJ r, <br /> Owner's Name �L -1-2 ��� Phone - <br /> Address <br /> hone -� b <br /> Address ry / � /�I� � ��� City/ Yf o z X7-0 <br /> 1 ,C �`.,. _.__., License �'237 3 Phoned 2 <br /> Contractor's Name _ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /�/ DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT 0157 i <br /> Other '/_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Do <br /> )( / 3 <br /> i <br /> PUMP•.REPAIR: State--Work Done 4 <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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW- P ,'T PLAN ON REVERSE SIDE) <br /> '0 DEPARPENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEP BY W/LSO DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION PHASE III/FINAL INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY DATE �J <br /> E H 1426 Rev. 1-74 3/76 2M <br />