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r <br /> ,V/ SAN JQAQUIN LOCAL HEALTH DISTRICT <br /> 0—R" OFFICE USE: ,,,�,,, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T6- 7p <br /> f THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued 6-1 S 7C <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 /> JOB ADDRESS/LOCATION - 1511-76 .�� � � � _. F16 CENSUS TRACT <br /> Owner's Name - % Phone <br /> Address <br /> City ,fast . <br /> Contractor's Name License #�Phone <br /> TYPE OF WORK (Check) : NE4ELL -/7 DEEPENj-7/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP. 6STALLATION / / PUMP REPAIR '/_7 PUMP REPLACEMENT <br /> Other <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESI 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 /> r Industrial Cable Tool Dia. of Well- Excavation <br /> Domestic/private Drilled Dia. of Well, Casing <br /> Domestic/public ._ Driven Gauge of Casing <br /> Irrigation =° C�. 6 i ave-1 Pack. Depth of Grout Seal <br /> Cathodic Protection, U?1. 1. Rotary Tg <br /> Other pe lof:Grout <br /> Disposal Other Information ' ' <br /> Geophysical Surface Seal Installed-'By:,.,', <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H'.P. <br /> PUMP REPLACEMENT: . / State Work Done A,,O3S �/� / .� ,;; <br /> J <br /> P yREPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter 1 Approximate Depth `11 ' <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 regui:ating well construction. Within FIFTEEN DAYS <br /> after 'completion of my work on a new well., I willr'furhish 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 FORA GROUT INSPECTIO <br /> PRIOR TO GROUTING AND A FINa IN PECTION. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED'I-BY = - DATE , V <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT.. INSPECTION P I IN INSPECT N <br /> INSPECTION BY _ DATE.;; . „INSPECTION B DATE <br /> EH 1426 Rev. -.1-74 <br /> 4/75 2M <br />