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F SAN J QUIN LOCAL HEALTH DISTRICT 1 <br /> FOFiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE Permit No. <br /> ., ' <br /> F <br /> THI$ PERMIT EXPIRES 1 YEAR FROM DATE ISSUE Date Issued MAY.2 4 1978 <br /> (Complete In- Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/6r. install the work herein described.. This application is mad in compliance with. San,,3aaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sa Joaquin Local Health District. <br /> JOB 4VBWf4ff9S/LOCATI ON Zb- il f- �fh _ Z ✓ ,� . - - CENSUS TRACT <br /> Owner's Name It LA 4/ I Phone <br /> Address .. City <br /> Contractor's Name 'y` License I, Phane�� Z�d . <br /> I <br /> TYPE OF WORK-(Check) :_ _NEW WELL _ -DEEPEN"/--/—RECONDfT'I-ON/Y/-i-DESTRU.CTION /— <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC:TANK; _,SEWER LINES­ PIT PRIVY ^- <br /> SEWAGE DIspcTsAL FIELD CESSPOOL/SEEPAGE PIT /-S=-,� OTHER <br /> PROPERTY LINE7-,!51PRIVATE DOMESTIC WELL = PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, 4 Dia. of Well Excavation ! /� _ <br /> Domestic/private �brillcd' T Dia.• -of Well. Casing �' <br /> F <br /> Domestic/public Driven Gauge of- Casing <br /> Irrigation ravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type -of Grout, <br /> Disposal i Other Other Information ` <br /> Geophysical ., Surface Seal Installed By: J <br /> C <br /> PUMP INSTkLATION: Contractor <br /> Type of Pump ,t H.-P. <br /> PUMP REPLACEMENT: / / ,State Work Done <br /> 1 <br /> PUMP .REPAIR: / / State Work Done + <br /> n <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure _ <br /> 1 <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 /> x 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 /> ' PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED TITLE <br /> (D?,-kV PLCT P ON REVERSE SIDE) <br /> FO DEP TMENT USE ONLY <br /> PHASE I <br /> 1, APPLICATION ACCEPTED BY �� DATE r7� <br /> ADDITIONAL COMMENTS: <br /> -RWE I OUT .INSPECTION r P SE III/ NAL INSPECTION Q <br /> INSPECTION BY :DATE 1 g INSPECTION BY DATE - `1 O _ <br /> E J <br /> 2H <br /> f� E H 1426 Rev. . 1-74 <br />