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F �� 1i L9 SAN JOAQUIN LOCAL HEALTH- DISTRICT T �� <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> '` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -l3a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1 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 /> d <br /> County Ordinance No. 1862 an the Rules and Regulations of th tSan Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �q li` CENSUS TRACT <br /> Owner's Name pC d r Xb Phone <br /> Address <br /> t -City, <br /> Contractor's Name <br /> tie.- License # ��'Ahone ezl, <br /> t <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / "RECONDITION f_1 . DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR ..1 PUMP REPLACEMENT /7 <br /> Other 'I / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <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 V <br /> Domestic/public Driven Gauge of Casing <br /> 7C Irrigation Gravel Pack Depth of Grout Seal F <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information, <br /> Geophysical Surface_Seal Installed By: <br /> PUMP INSTALLATION: Contractorppg <br /> Type of Pump H.P. PZt, <br /> PUMP REPLACEMENT: /. / State' Work Done <br /> PUMP .REPAIR: X/ - .State Work Done c J i <br /> DES-TRUCTION OF WELL: Well' Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall .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 cpmpletion 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 - my..knowle e an belief, I ,WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALJI E IO <br /> SIGNED ' -TITLE <br /> pi, T' PLAN ON E SIDE -.7.17 <br /> F EPARTMET USE ONLY <br /> PHASE I <br /> APPLICATION ACCE BY X13 V E DATE ` ' ZF <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ] /FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �l <br /> E 'H 1426 Rev. '1-74 2M � <br />