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SAN JOAQUIN tZC9t HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 4J <br /> 76-9 s 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ZeZ:L_)6 <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 /> JOB ADDRESS/LOCATION TU44 VgR p, CENSUS TRACT l Qty 26 <br /> Owner's Name Phone JZY f <br /> Address City <br /> Contractor's Name �' t License Phone "�f � <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN '/ RECONDITION /_7DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR,/-7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 6 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELT. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A—Cable Tool Dia. of Well Excavation <br /> IlDomestic/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 GroutO <br /> Disposal Other Other Information t ' <br /> Geophysical Surface Seal Install d BY: <br /> PUMP. INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: W61.1 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws amd 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 <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 GROUTJNG--AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ] <br /> ADDITIONAL COMMENTS: r <br /> PHASE 11 G OUT INSPECTION PHASE III FINAL INSPECTI N / <br /> INSPECTION BY DATE G INSPECTION BY DATE / �s <br /> E H 1426 Rev. 1-74r _ 4/75 2M <br />