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SAN JOAQUIN LOCAL HEALTH DISTRICT ,Q ` <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 'I <br /> !f �, RPer P Telephone : (209) 466-6.781 7� s-/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 �' <br /> 07r— :V-4777 (Complete In Triplicate) i <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 /> JOB ADDRESS/LOCATION 60,JL CENSUS TRACT Z3 <br /> Owner's Namef Phone 334 <br /> 1 <br /> Address 3 IQ e fCity <br /> Contractor's Name License <br /> s' <br /> TYPE OF WORK (Check) : NEW WELL Y DEEPEN/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR-f-7/7 `PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �-f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD &r1, CESSPOOL/SEEPAGE PIT OTHER* <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 'C'' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �+ <br /> Domestic/private Drilled Dia: of' We11'7Casing, . .A/OZ <br /> Domestic/public Driven Gauge .,of Casing <br /> Irrigation X Gravel Pack Depth of Grout Seal Z� <br /> Cathodic Protection Rotary Type of"Grout., . . a :t19 /' e � <br /> Disposal Other Other Informatibn <br /> Geophysical Surface Seal _Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> �Te'� of Pum H.P.. <br /> yP 3 <br /> 1 _ , P> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> ff <br /> PUMP .REPAIR: / / State Work Done I <br /> i DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure s <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 caellr'construction. ;� Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish',3'the#San-Joaquin.Loca1 Health District a <br /> WELL DRILLERS REPORT of the well and notify them before p thing the .well in use. The above <br /> information is true to the best f' my knowledge and belief.. 'IWILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU.TR6 AND IN PECTIO . <br /> SIGNED TITLE <br /> .� W PLT PLAN''ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE--I <br /> APPLICATION ACCEPTED BY DATE loll <br /> ADDITIONAL COMMENTS: <br /> PRASFJI CAOUT INSPECTION y PHAS --I. FINAL INSPECTI' N <br /> INSPECTION BY DATE - 2-0"?O INSPECTION BY- - f DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />