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L <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' jl OWFICE USE; - <br /> 1601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephone: ` (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 5 <br /> THIS PERMIT. EXPIRES l YEAR FROM DATE ISSUED Date Issued r�._Aa.g77 <br /> ti (Complete In Triplicate) <br /> application is hereby made to the Sala joaquin.Local Health District for a pea.`mit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862. an"d the Rules and-Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION ' i' _ r C_ IC �� kJ ENSUS TRACT <br /> Owner's Name Phone <br /> Address QLf City 91,2 o.i <br /> Contractor's Name �c I ` ;, `-O. <br /> . License Phone3ff--3 yS6, <br /> �j <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN j7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION IE/ , 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 WELLPUBLIC- 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 <br /> Domestic/public . ,- -Driven_, -.-,-7---Gauge---of-Xas ing - - - n—E <br /> �Irrrgaton r Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 17- Rotary Type of Grout <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed By: ,.... <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. "Cs <br /> PUMP REPLACEMENT: / IT State Work Done <br /> F � k <br /> PUMP ,REPAIR: /7 State Work Do one <br /> j <br /> E&TRUCTION OF WELL: Well Diameter <br /> 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 TITLE 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE, <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> APPLICATION ACCEPTEDSY DATE �7 l <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION _jLAgAI34qjNa INSPECTI <br /> 99 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br /> R, <br />