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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OPWICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-1� <br /> 4,o opea•- , e f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (okr_r*-4 ,ewtX Z"s,"7, (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 /> 149 <br /> JOB ADDRESS/LOCATIONr T J -d<p tO k,ij <br /> A:kIiA^=W CENSUS TRACT <br /> Owner's Name _.__ ✓ -� �"-G( 1��??,-1�- . .,._,.-,--- Phone <br /> AddressCity_ . <br /> ,�.� _— <br /> Contractor's Name viev" a License # .1-1— <br /> hone � <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /7 RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / I PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other E7 <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 <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: w. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 C, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done ,' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> T 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 arf my w -edge-,_and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO qQUTING AND A FINAL INSN <br /> SIGNEDL Or dcsomld6f_� <br /> ITLEE,,f' C <br /> Z D W-PLIDT PLAN ON XFVhEhh SIDE) - t' <br /> kor FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE 4 <br /> E H 1426 Rev. 1-74 � <br /> 3/76 2M <br />