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a` SAN JOAQUIN LOCAL HEALTH DISTRICTS - <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7Z- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3- <br /> A-.27 <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 Joaquin Local Health District. ; <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone 3�S 7ag) <br /> Address City T,Odj <br /> Contractor's Name Wal i r r Cr_ Nn rk . -- _ -- License # n_7Whone <br /> , <br /> TYPE OF WORK (Check) : NEW WELL/_/ DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT -7 <br /> 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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing � a <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout Z41 <br /> i <br /> Disposal. Other Other Information " <br /> Geophysical Surface Seal Installed B w � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL; Well Diameter 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 <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 TITLE <br /> l]RAW:PL TjPLAN 'ON REVERSE SIDE <br /> DEPART ' . T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP C>LS /t! DATE 2 <br /> ADDITIONAL COMMENTS: } <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATES <br /> • � 3/76 2M <br /> E H 1426 Rev. 1-74 <br />