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s SAN JOAQUIN LOCAL HEALTH DISTRICT <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. <br /> A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T-23-7p <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 /> County Ordinance No. 1862 and the Rules and R gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .-&�� — �� t� _ - -- - CENSUS TRACT ' <br /> i Owner's Name Phone <br /> r Address 4k-%-k- F City <br /> Contractor's Name k. - License # 'S01Q7� Phone -cry <br /> f � �.� <br /> TYPE OF WORK (Check) ; NEW WELLS/ DEEPEN '/ RECONDITION' / / DESTRUCTION /-7 <br /> 3 PUMP INSTALLATION/PUMP REPAIR/ / PUMP REPLACEMENT /-T <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK p��SEWER LINES �� PIT PRIVY pW_ G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY TINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 'I ` <br /> --i�7 Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> #Irrigation , 1 Gravel Pack Depth of Grout Seal <br /> i� <br /> Cathodic Protection ! ✓Rotary Type of Grout <br /> N Disposal Other Other Information -- C F.. ,. <br /> *1 ,.Geo,physical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t Q + <br /> Type of Pump H.P. <br /> i r <br /> PUMP REPLACEMENT: / / State Work Done r <br /> -4 <br /> PUMP .REPAIR: / / , State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .. Approximate Depth <br /> DescribeMaterial and Procedure <br /> k <br /> 4I- hereby agree to comply with all laws and regulations of the Saiz Joaquin Local Health District and the State of California pertaining to or regulating well construction. /Within,FIFTEEN DAYS <br /> 1.: <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 /> informa ion is true to the bes ' of .knowledge and belief. > I WILL CALL FOR•"A GROUT INSPECTION <br /> PRIOR TO OUTING AND A S CT N <br /> SIGNED 4 TITLE R MA C27e " <br /> W P=T PLAN ON RE FRSE S IDE} ----� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s i � -� DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE I " FIN6L INSPECTION <br /> INSPECTION BY ], DATE 2-3! /.2� INSPECTION BY DATE.-, <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />