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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. 2,�-,.39, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s._.-LzL-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 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 l4 CENSUS TRACT <br /> Owner's Name � Phone <br /> i AddressZ:� c�7 �c��^ �� Citys-1-6 <br /> Contractor's Namo License /u7-3-;qhon&"G <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN RECONDITION RECONDITION / / DESTRUCTION /- ` <br /> PUMP INSTALLATION0�=AR /_ / _,�UMP�LACEMENT <br /> Other / / <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 r�1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS vl <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 <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 Done) <br /> C <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 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 -j-M i <br /> DRAW-PL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION 'ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/ INAL INSPECTION <br /> INSPECTION -BY DATE INSPECTION BY DATE <br /> E> R H 142E Rev_ 1-74 3,76 2M <br />