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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> M FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f' Telephone : (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z&_Z4e,�2 7 , <br /> THS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2,2-q.24' <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 andReaul.ations o he San .Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's <br /> Name Phone <br /> Address v2&4 ��� <br /> City <br /> Contractor's Name ' License #ff Phone ` <br /> TYPE OF WORK (Check): NEW WELL/ J DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Otherp/ <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES PIT PRIVY <br /> IE .SEWAGEIDISPOSAL -FIEI;D ' '' _CESSPOOL/SEEPAGE PIT _OTHER , <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . I Cable Tool Dia. of Well Excavation <br /> Domestic/private 4 Drilled Dia. of Well Casing C4 <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal p, <br /> Cathodic Protection I Rotary, Type of Grout <br /> Disposal [ Other.,, Other Information ' <br /> Geophysical �; - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type hof Pump H.P. <br /> - _ <br /> 1 <br /> PUMP REPLACEMENT: ' / '/ State Work Done <br /> PUMP REPAIR: ' <br /> State Work Done <br /> J <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 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 C FOR A GROUT INSPECTION <br /> PRIOR TO G UTING A-VINAL INSPECTION. <br /> SIGNED TITLE <br /> D W- PL T' PLAN ON REVERSE SIDE) ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p / <br /> APPLICATION ACCEPTED BY DATE / Z� -7-b <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II UT INSPECTION PHASE,,r,1,1/FINa INSPECTION 1 <br /> INSPECTION BY IV Z h DATE INSPECTION BY DATE ;k <br /> E H 14�2-6,,.,, Rev. -1-74 3/76 2M <br />