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r es M?/0Fo efO l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 42_,?_7,f <br /> I <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 sby4 <br /> /and Regulations/of// the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Ot1,11ft/da G7 �J 1 X Aj'j yo r ENSUS TRACT <br /> Owner's Name P O/J tt rG(/' 1// fC. AwIt . Phone <br /> Address /4L(,..Zg J,' ���n,�/ ,sY City �To <br /> Contractor's Name,.�l --� License #/ _4-72-- Phone � �G <br /> i <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN�/_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / PUMP REPAIR /_C� PUMP REPLACEMENT /? <br /> Other t/ / <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES -PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,.I Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public a Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal 'I Other Other Information <br /> Geophysical 1f} Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor \)��n✓ <br /> Type, of Pump Tim✓ri H.P. <br /> PUMP REPLACEMENT• t <br /> State Work Done <br /> AP X­ <br /> PUMP`:.REPAIR: . tate Work Done es b "Isepry sR1'Ne 1 .1;�/ o5bla p <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 knowledg d belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO G UTING AND A FINAL! INSP CI N <br /> SIGNE TITLE <br /> ! W P PLAN ON FRSE SIDE ';.": <br /> FO D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT Y DATE <br /> TIONAL COMMENTS: 1 <br /> PHASE II GR UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 76 <br /> ,1. <br /> E H 1426 Rev. 1-74 " 3/76 2M <br />