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(/ SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOFi.IRFICE USE: ////// 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. 7�o <br /> THIS PERMIT (EXPIRES I YEAR FROM DATE.'ISSUED Date Issued /Q A-7S- <br /> f <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 <D2 1Sy/ r Ute . CENSUS TRACT <br /> Owner's NameG ' Phone ' <br /> Address �S� /. . <br /> s <br /> /� �d Q r, City <br /> Contractor's Name mlv 3 <br /> License. #/ �.,1"ghone o276?6 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/? RECONDITION /7 DESTRUCTION <br /> 1-7 <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMEN' 1? <br /> Other 1/-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 /> x <br /> Domestic/private <br /> Drilled <br /> r Domestic/public � r Dia. of Well Casing \ <br /> Driven Gauge of Casing �{ <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary _ Type of Grout: <br /> Disposal I Other Other Information ' <br /> Geophysical � - Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor .; ( 1 <br /> Type of€€ Pump H.P. <br /> I � t <br /> PUMP REPLACEMENT; .,,. State Work Done <br /> PUMP :REPAIR: /x7 State Work Done C%4, e r <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Approximate DepthJE�AYS <br /> j <br /> Describe Material and ProcedureI hereby agree to comply withrall laws and regulations of the San Joaquin Local Health Dist-and the State of California pertaining to or regulating well ��construction. Within FIFTEEN after completion of my work on anew well, I will furnish the San Joaquin Local Health Dist ! <br /> WELL DRILLERS REPORT of the we11 and notify them before putting the:.well. in.use.... .The above <br /> information is true to-the-bes.t.of my wled e an—Ve-1 of.. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO NG AND A PINAL 'INS �d <br /> SIGNED <br /> (D "W LOT PLAN ON REVE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ,. <br /> PHASE II GROUT NSPECTION E TMPIZJAL INSPECTIONi <br /> INSPECTION BY DATE INSPECTION Y DATE L C <br /> E H 1426 Rev. 1-74 '�'_- <br />