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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "V <br /> FOFx;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ ! Telephone: . (209) 466-6781 ►, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-.2ao1� <br /> THIS. PERMIT EXPIRES 1 YEAR-,FROM DATE 'IS'SUED Date Issued Y-9-7 <br /> a (Complete In Triplicate) <br /> Application is hereby'made to the San Joaquin Local. Health Mistrict� for r: 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 Locel .Health District. <br /> _ t <br /> JOB ADDRESS/LOCATION - � 14wLL. V&.: : ` � / CENSUS TRACT - <br /> Owner's <br /> RACT Owner's Name ;.�c _ � ' W - Phone oGa <br /> Address � �'�]'� ,*gAt& ,��. .. _ Cit s�%3�►O� - <br /> Contractor's Name <br /> �' c�� 'd License &2170 0 Phone <br /> � , , t, Qw <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION ./-7 DESTRUCTION /7 <br /> PUMP INSTALLATION-/ / PUMP REPAIR-/ <br /> PUMP REPLACEMENT <br /> w :Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ,, t <br /> SEWAGE DISPOSAL_FIELD, — CESSPOOL/SEEPAGE-PIT - OTHER' <br /> _ PROPrfZV Y LINE - PRIVATE DOMESTIC WELL" _ _PUBLIC DOMESTIC WELL <br /> INTENDED USE- TYPE OF WELL CONSTRUCTION SPECIFICATIONS t ; <br /> Industrial Cable Tool Dia. #of Well-Excavation, <br /> r Domestic/private t Drilled Dia. of ,Wel1-Casing �� <br /> Domestic/public ;�. Driven Gauge of Casing t- -.: .-. ; <br /> Irrigation Gravel Pack Depth of 'Grout Seal <br /> Cathodic Protection f Rotary Type of Grou'ty"' <br /> Disposal t Other Other Information x <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type .of Pump x` H.P. f <br /> PUMP REPLACEMENT: . State Work Done ' <br /> PUMP REPAIRi / / State Work Done <br /> DESTRUCTION OF WELL: Well._biameter;.2 '� 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 <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'af- my..knowledge and belief. I WILL CALL OR A 'GROUT INSPECTION <br /> PRIOR TO GRO NG FW <br /> AL INSPECTION., <br /> SIGNED - - TITLE <br /> = i (DRAW PLOT PLAN ON REVERSE SIDE <br /> ! FOR�DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY \\ .. DATE �'�`116 � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA INSPECTION <br /> .INSPECTION BY DATE . INSPECTION BY DATE <br /> E H 1426. ,.. Rev.t 1=74- r 4/75 2M <br />