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_ ;C--6 qA.N JOAQUIN LOCAL. HEALTH DISTRICT <br /> --FO-F,-'OFFICE USE: l 16,.., E. Hazelton Ave. , Stockton, Citi. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-1,7- <br /> (Complete <br /> ;-17-(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 Joaq <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION `'10 CENSUS TRACT <br /> Owner's Name ��,� 621 Phone -551 <br /> Address City <br /> r� <br /> Contractor's Name /�a�-�G %d�t� z License -r Phone Y <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / - <br /> _/ DESTRUCTION / _ <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 DOMESTIC [JELL �/PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation -1-9"' <br /> Domestic/private Drilled Dia. of Well Casing 1/61 <br /> Domestic/public Driven Gauge of Casing /p` <br /> Irrigation Gravel Pack Depth of Grout Seal z <br /> Cathodic Protection _� Rotary Type of Grout � ._- -/ y 7-•, _ �__ - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: /j per, � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ,Z-46 2LZ-, H.P. f <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-vell 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 GRO N INAL N CTIQN. <br /> SIGNED r C`Lif TITLE --- j__ zL_ <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPA TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE % 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />