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`I JOAQUIN LOCAL HEALTH DISTRICT <br /> F6 OFFICE USE: 06 160` -E. Hazelton Ave. , Stockton, Cam . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-? ,3 GL <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $ -77 <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 �_ CENSUS TRACT • <br /> Owner's Name Ca y s,•� �' Phone 34f5 - Z76 l <br /> Address ���� �� �!l,Ccl City <br /> Contractor's Name (• �i�o.SS �JPLL «i ticj License 1/cav-ox Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /CONDITION. /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK — ' SEWER LINES _ _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINT. - PRIVATE DOMESTIC WELL _—_ PUBLIC _DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \. <br /> Industrial L,----Cable Tool Dia, of Well Excavation <br /> A.-,' Domestic/private Drilled Dia. of Well Casing 6� <br /> Domestic/public Driven Gauge of Casing !C2 <br /> 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 ump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP 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 <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 INSPECTIO <br /> PRIOR TO GROUTINIG ANP A NAL CT <br /> SIGNED 21 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 41 <br /> APPLICATION ACCEPTED BY DATE 41,92 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSFECTON PHASIh III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE., <br /> 0/77 2M <br /> EU 1426 Rev- 1-74 <br />