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r SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLIMUTION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /2-1 S-,;K <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 /> .FOB ADDRESS/LOCATION 70 I 2 • E 7'Z/��t-_�_.L,f 4 .. `. CENSUS TRACT <br /> Owner's name Phone i?Z?8 <br /> Address city <br /> Contractor's Name5� �y .. License ��a Phone <br /> � <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /%PUMP REPLACEMENT <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 Q <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: Jam( State Work Done V6,on <br /> P17MP :REPAIR: /_7 State Work Done <br /> 4ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and -Procedure T T <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 GROUTWG ,AND A FINAL SPECTION. <br /> SIGNEDUIAEVTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> _.._ 51 <br /> _._..._._._.FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY �!e ,r DATE /D -/41-76 <br /> ADDITIONAL COMMENTS: ' _-- <br /> PHASE II GROUT INSPECTION PHA I INSPECTI <br /> INSPECTION BY DATE INSPECTION BY r DATEGll <br /> `1 µE H 1426 Rev. 1-74 1-74 2M <br />