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6)• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> — Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued e44Z„77 <br /> (Complete In Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct r <br /> pp <br />' and/ar install the warkherein described. This application is made in compliance with San Joaquin <br /> County Ordinance No.�18162 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 �- <br /> CENSUS TRACT <br /> Owner's Name <br /> it" <br /> Il4- F �' Phone 3 6 o - 7 �l 3 <br /> i <br /> Address 4 A/ City Z-01)/ <br /> Contractor's Name License Phone y � <br /> 7� <br /> TYPE OF WORK (Check) : .,'NEW WELL/� DEEPEN / I RECONDITION / / DESTRUCTION /7 <br /> :PUMP INSTALLATION '/ / PUMP REPAIR PUMP REPLACEMENT I <br /> .I Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial- �y� - ._: Cable_Tool. _ _ Dia.-.of Well- Excavation— <br /> Domestic/private <br /> _ . <br /> C� Domestic/private, .. #Y Drilled Dia. of Well Casing <br /> Domestic/publici Driven Gauge o Casing Vs <br /> Irrigation ;:Gravel Pack— Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other . Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor °' H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / s State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> i <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 <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•IA FINAL INSPECTION.. .1 <br /> SIGNED #:Pitt <br /> 000, TITLE <br /> LAN N REVERSE SIDE ------------------- <br /> ; <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I / <br /> APPLICATION ACCEPTED�;BY DATE 7 �G <br /> ADDITIONAL COMMENTS: II <br /> PHASE II GROUT INSPECTION PHAS F,NAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE t/� <br /> 3/76 <br /> E H 1426, Rev. 1 .74 <br />