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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: M) 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' I-1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r -N- 77 <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 6 , L . CENSUS TRACT <br /> Owner's Name Phone g 38-,�7 <br /> Address ?'y City It-- ,Sc&j20,j <br /> Contractor's Name License Phone g j-; CJ'7 <br /> i <br /> TYPE OF WORK (Check') : NEW WELL --/ / -DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR "/_/ PUMP REPLACEMENT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 1 <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 k, <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/privateT' 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. ih <br /> PUMP REPLACEMENT: X/ 7 State Work Done <br /> PUMP -REPAIR; / / State Work Done. . <br /> DESTRUCTION OF WELL: Well Diameter ---- Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree t6-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 FQR A GROUT .-INSPECTION <br /> PRIOR TO GROUTIbW AND A FANAL NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ��- <br /> ADDITIONAL COMMENTS: <br /> PHASE 11VROUT INSPECTION PHASW II FINAL INSPEON - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> y19. <br /> E H 1426 Rev. 1-74 1177 _ 2M <br />