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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> f FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27/p /O <br /> E} THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �j <br /> r (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 aRulesand <br /> sdThis Regulatiansofthe <br /> an <br /> tnis San Joaqu nLocal <br /> ade in pewith HealthSDistrict�n <br /> County O=dinance No. 1862 and th <br /> JOB ADDRESS/LOCATION �J 1 I�r d R V . I A wn CENSUS TRACT <br /> Phone � �� d ci1- <br /> I ' Owner's Name a! /� �- <br /> I" <br /> Address -_ i c1� �'d""[ _ <br /> City 'mac� Td r- <br /> Contractor's Name <br /> U ,. License # Phone - <br /> � �' - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /�I RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /V/ PUMP,_REPAIR j/`°I PUMP REPLACEMENT /7 <br /> �. ... w Othier_/ / <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 F _ _ Y _-CONSTRUCTION SPECIFICATIONS \' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private i <br /> Domestic/public Driven Gauge ofCasing <br /> 1 . <br /> Irrigation Gravel. Pack Depth- of Grout Seal. <br /> Cathodic Protection Rotary _i_ Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> 17 <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> ' PUMP REPLACEMENT / /� State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 /> well, I will furnish the San Joaquin Local Health District <br /> after completion of my work on a new <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above - <br /> WELL WILL CALL FOR A GROUT INSPECTION <br /> information is true to the best of my-knowledge and belief. <br /> PRIOR TO GROUTIN AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W 6�� <br /> PL T PLAN� ON RE EASE ST'�E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 2.2 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHA I/FINAL INSPECTION <br /> a P S II GROUT INSPECTION DATES 1� <br /> INSPECTION BY DATE I.IVSPECTION BY <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 = <br />