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b <br /> g SAN JOAQUIN LOCAL HEALTH. DISTRICT 31717,7 <br /> /7 � <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6-,—2 .4.1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 30 <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 /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name (�'i e T f'Ov zr� Phone �'3//-7��7( <br /> Address -e- City <br /> Contractor's Name e- License # Phone <br /> • i <br /> TYPE OF WORK (Check) : ` NEW WELL/ / DEEPEN '/_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other / l <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 <br /> Domestic/public Driven Gauge of Casing i <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 rR M rg ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 'Well Diameter Approximate Depth /&-V 474 <br /> De tribe Material. and Procedure w Sd�-� i 7 <br /> Jrk!rL ce I j ,o r. <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 IQ GROUTING AND A FINAL I ECTION. <br /> SIGNED . . . TITLE <br /> „ <br /> KDRAW, rwr PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FI AL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �/!�� . �` L'G, 3/76 34 <br /> E H 1426 Rev. 1-74 i <br />