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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> __.q, Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued -, 316 <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 egulationsQof the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6� c,] CENSUS TRACT <br /> Owner's Name rM - V� Phone Y5 3_24. _ <br /> Address 7Qla o!'- City Ar� <br /> Contractor's Name <br /> License # Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /- <br /> PUMP INSTALLATION _Z/ PUMP REPAIR / / PUMP REPLACEMENT �T <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 WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REP / / State Work Done <br /> & <br /> D S•TRUCTION OF WELL; 11 Diameter If-" 6 Approximate Depth y� <br /> Describe Material and Procedure LL6d G✓ Go�vGG7 , <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.-knowledge and belief. I WILLJL <br /> FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INVECTION. <br /> SIGNED 2 TITLE <br /> DRAW PIs T PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE /y-7 <br /> APPLICATION ACCEPTED BY C/� <br /> ADDITIONAL COMMENTS: <br /> PHASE UT INSPECTION PHASE II / INAL SPECTION / <br /> INSPECTION BY DATE INSPECTION BY <br /> 3/76 2M <br /> k. E H 1426 Rev. 1-74 <br />