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SAN JOAQUIN LOCAL HEALTH DISTRICT / l � y <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. `' <br /> �` Dom/ <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMI ermit No. r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuejAN 3 - 1978 <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 JoeQuin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5gf ,4!e:� 6�,Q� ,v CENSUS TRACT ' <br /> Owner's Name Q Phone L/ <br /> Address A2 CP City <br /> Contractor's Name --.License-#-- -- •Phone <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN '/% RECONDITION / / DESTRUCTION /-7 <br /> I PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /' / — G✓e I? <br /> AL7- 401 <br /> DISTANCELTO NEAREST: SEPTIC TANK iSEWER LINES /a, PIT PRIVY <br /> SEWAGE DISPOSALFIELD/V d I CESSPOOL/SEEPAGE PIT OTHER <br /> J PROPERTY LINE - PRIVATE DOMESTIC WELL —0PUBLIC DOMESTIC WELL <br /> INTENDED,`USE TYPE OF WELL `+,� CONSTRUCTION SPECIFICATIONS C <br /> Industrial <br /> 1,,� .e, Cable Tool Dia. of Well Excavation : � <br /> Domstic/private ---- Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation / Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ' f Rotary Type of Grout t <br /> Disposal �� �'#.• Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: I v <br /> 4 f <br /> PUMP INSTALLATION: Contractor <br /> n <br /> Type ofsPumpeZZXkpSI ;7 - L7 t H.P. — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIRt State Work Done <br /> r � <br /> DES-TRUCTION 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 a <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 WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUT;XC AND INAL ECT ION <br /> SIGNED TITLE ,' <br /> I (DRAW LOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � E <br /> kPPLICATION ACCEPTED BY DATF1 Z-2- - ^7 <br /> kDDITIONAL .COMMENTS: <br /> PHASE II GROUT INSPECTION,/A _ PHASE jjL/FINALjTrNSPECTION <br /> INSPECTION IbY DATE INSPECTION BY ATE <br /> V <br /> E H 1426 Rev. 1-74 2M <br />