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. .M.— / :, x�. <br /> e r / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OF <br /> FOFr. FIGE USE: VVV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIOW OR PUMP PERMIT Permit No. <br /> �9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' -�1/,-76 <br /> kj_6o1'5-a/f/ (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 Saab, Joaquin Local. Health District. <br /> JOB ADDRESS/LOCA ION & V .- <br /> CENSUS TRACT 0 ` -370--03 <br /> Owner's Name �,� Phone <br /> Address Citlr <br /> Contractor's Name tense Phone - <br /> I <br /> TYPE OF WORK (Check) : NEW WELL 'O' DEEPEN -/7 RECONDITION /_7 7 DESTRUCTION /_7 <br /> PUMP INSTALLATION. PUMP REPAIR / ] PUMP REPLACEMENT 17 O <br /> Other Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK 162 SEWER LINES - PIT PRIVY <br /> SEWAGE DISPOSW FIELD _ CES POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE » PRIVATE D MSTIC WELL ' PUBLIC DOMESTIC WELT. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial able Tool, Dia. of Well Excavation � 1 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _L-,�__ Irrigatioh - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �`1 <br /> Disposal Other Other Information N <br /> Geophysical <br /> Surface Seal Instal ed 'B : <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of. Pumpjy <br /> PUMP REPLACEMENT: � <br /> State Work Done <br /> PUMP .REPAIR: /% State Work Done l r <br /> i <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 we11 'construction. Within FIFTEEN DAYS' <br /> t+ <br /> after completion of my work on.a new well, I will furnish the San Joaquin Local Health District] <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 C^L FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU G 'AND A FINAL SPE TON. r- <br /> SIGNED TITLE <br /> (DRAW P PLAN ON �ROSE SIDE <br /> FOR PARTMENTNLY <br /> PHASE I V . <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ou <br /> PHASE II GROUT INSPECTION PHASE IU/FIN INSPECTN <br /> INSPECTION BY .W_ DATE INSPECTION BY ATE /p <br /> E H 1426 Rev. 1-74 !./aC ou <br />