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kSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOZFFICE U991: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L6-3,;111. <br /> 6-3a1. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date leaved -/ -76 <br /> (Complete In Triplicate) <br /> Application 3s 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 .Hearlth District: <br /> i <br /> JOB ADDRESS/LOCATION q 9 -' _ <br /> dQ CENSUS-TRACT <br /> Owner's Name Phone - 3 <br /> Address 9 City,' <br /> Contractor's Name �d License #/ Phone <br /> �' �`s� w "ice.✓ .. w � ik, ".�Y -. - �.. - _ _.. .-- - x - '- - <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN 47 RECONDITION /7 DESTRUCTION J7 <br /> PUMP INSTALLATION/ / PUMP REPAIRPUMP REPLACEMENT- 17 <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 <br /> INTENDED USE ,TYPE OF WELL CONSTRUCTION SPECIFICATIONS V3 <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 4 Surface Seal Installed By: <br /> PUMP INSTALLATION: ' Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br />`PUMP-,REPAIR:- <br /> r° ,:..,"/ .State"Work Done - ...---� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 AA, M, P TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1. DATE, ��S 7 <br /> ADDITIONAL COMMENTS; <br /> S' S <br /> PHASE II 9WW I P TIO PHAS FINAL INSPECTIO <br />'INSPECTION BY DATEik- <br /> INSPECTION BY DATE <br /> - <br /> E H 1426 Rev. 1-74 !. h7e �ha <br />