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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOK,;,OFFICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> [/ Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6- .I-q I.,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued _30- 76 <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 Regulations of the San Jqaquin Local Health District. <br /> to 10-3 N- lf.g - cam✓ - o 5-1?—v - 24 <br /> JOB ADDRESS/LOCATION d CENSUS TRACT <br /> Owner's Name D /¢ Phone 7-11 Q:�r <br /> Address U �}��'.�✓ .tl' City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL LF DEEPEN -/-7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION /' / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other E/ <br /> DISTANCE TO NEAREST: SEPTIC TANKAEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER { <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation l <br /> Domestic/private X Drilled Dia. of Well Casing G <br /> Domestic/public <br /> /p Driven Gauge of Casing r y- <br /> Irrigation -Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Disposal -+:v 'Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> � I <br /> Type of Pump .,. H.P. IL <br /> PUMP REPLACEMENT: . / / State Work Done <br /> .PUMP-:REPAIR:- ._. /7- State Work Done. <br /> DESTRUCTION OF WELL: Well Diameter ir 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-Of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED AW.,soof <br /> j_' TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 130 <br /> ZZ <br /> ADDITIONAL COMMENTS: <br /> P SE II ROUT INSPECTION PHASE,,IWFINAL INSPECTION <br /> INSPECTION BY,t .. DATE S�y 7l INSPECTION BY Vii.. _ DATE /- /-Z . <br /> E H 1426 Rev. 1-74 --- 4/75 2M <br />