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/ C <br /> ['o 0% .1- p4r' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFF1 E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J7-x,31 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-6-7 7 <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 /> r <br /> JOB ADDRESS/LOCATION 2 � CENSUS TRACT <br /> Owner's Name ,c 4 f Phone <br /> Address /l Ti,//v <br /> City 1i2�G� <br /> Contractor's Name + <br /> ,p,•-•-~'�'"�tJ License # /?-,g -7:.. Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION / / DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION /�/ PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other /_7 "'y <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 N! <br /> Irrigation Gravel Pack Depth of Grout Seal IN$ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: R <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. <br /> e <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter f 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 I <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 7 knowledg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> t <br /> PRIOR TO GROUTING AND A FINAL INSP CT 0 <br /> SIGNED �,�! TITLEjrp.�' <br /> LOT PLAN ONvREVERSE SIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � g2 DATE Z /or-/Z 7 <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT NSPECTION PHAS I/ NAL INSPECTIO <br /> INSPECTION BY /t/ . DATE INSPECTION BY DATE L641-V7? <br /> E H 1426 Rev. 1-74 1 f77 2M ,, <br />