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Ab L� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 0 ICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2z 7__;o <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 31.7 7 <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 :Wade 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 �� u, + e *, g" k)/4r ter . CENSUS TRACT <br /> ,/� <br /> Owner's Name [ /�+•f� iY Ott __ Phone <br /> Address .ir. ' /.rr �°' City <br /> + I � ,� License # Xj`Ttione <br /> Contractor s Name .� �� <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN I I RECONDITION I / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <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 I Cable Tool Dia. of Well Excavation <br /> Domestic/private R Drilled, Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing 1 <br /> _ Irrigation L Gravel Pack Depth of Grout- Seal <br /> -Cathodic Protection i Rotary Type of Grout <br /> Disposal .. 1 Other Other Information <br /> Geophysical Surface Seal. Installed B <br /> PUMP INSTALLATION;- Contractor <br /> H.P. <br /> Type of Pump �" ', ,�,� • � �) <br /> PUMP REPLACEMENT: / / State Work Done . <br /> PUMP .REPAIR: /x/ State Work Done ,./ <br /> DESTRUCTION OF WELL: Well Diameter a 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 j est„of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOpGROUTING AND A FINAL! P•ECTtON� - <br /> SIGNED °` ' ,) J _ TITLE <br /> i v 1 �...:;; �„ D � PL T' PLAN 'O ARE FRSE SIDE I• <br /> .__ _._ - <br /> �' V" FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY l DATE t- "1 <br /> ADDITIONAL COMMENTS: <br /> PHASE- 11 GRO SPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -� ' ) _ <br /> �. t. <br /> 3/76 2M <br /> 4 E H 1426 Rev. 1-74 <br />