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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit,No S <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued o7� 6 J,�' <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 He-�i't1th District. <br /> z � <br /> JOB ADDRESS/LOCATION CENSUS .TRACT <br /> Owner's Name f 74) G✓�. �f` ne d T��"�7�T <br /> jkAddress City _ <br /> � <br /> Contractor's Name License Pho4m <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / - PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -VA <br /> SEWAGE DISPOSAL FIELD CESSPOOL,/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION" <br /> Industrial Cable Tool Dia. of Well Excavation h <br /> Domestic/private Drilled Dia, of Well Casing (� <br /> Domestic/public ' Driven Gauge of Casing + <br /> Irrigation Gravel Pack Depth of Grout Seal S <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <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 DepthT <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 /pfj <br /> (DRAW PLOT PLAN ON REVERSE SIDE)�� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE ?9 INSPECTION BY DATE 7 <br /> 16/77 _ 2M'-f7/ = <br /> E H 142266 Rev. - 1-74 �, <br />