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SAN JOAQUIN LOCAL HEAL'T'H DT ;'1RICT <br /> r_ OFFICE USE: / 1601Y. Hazelton Ave . , Stockton, Cal_, <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> %'7 177 p <br /> THIS PERMIT EXPIRES JI YEAR FROM DATE ISSUED Date Issued 3-3-?7 <br /> (Complete In Triplicate) <br /> Application is Lereby 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 three Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Xz �� CENSUS TRACT <br /> Owner's Name Le3(,k- <br /> Phon <br /> Address City <br /> OF <br /> Contractor's Name 40 j License #1(,13 )_3 PhonE3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION � PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMES'T'IC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �[_ Cable Tool Dia. of Well Excavation 0 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> public Driven Gauge of Casing 10 <br /> __L(_ 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 �`. � H.P. / — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUt? REPAIR: / / State Work Done <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 kry6wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRICR TO GROU22C D A FI INSPECTIO . <br /> SIC74ED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ' . DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />