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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif.. _ 4 <br /> Telephone: (209) 466-6781 K' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;ZZ- IZI <br /> J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE.-ISSUED Date Issued <br /> I(Complete In Triplicate) 05t-1(0-(P <br /> Applicatioriis her=eby made'to�the-San Joaquin Local Health District for a permit 'to construct <br />' and/or install the work .herein described. This application is trade in compliance with San Joaquin <br /> j County Ordinance No. 1862 and. the Rules and Regulat'o. s of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ..tom CENSUS TRACT <br /> Owner's Name Phone_TA/, <br /> Address _�J/ / % 7Y,4 �,L /Q _._�f O ! �� L'/ r. City <br /> Contractor's Name � � = icensePhon& f <br /> TYPE OF WORK (Check) : YNEW WELL /!�EEPEN / / RECONDITION _/_ DESTRUCTI69'/_7 <br /> PUMP INSTALLATION'/ / PUMP REPAIR %/ PUMP REPLACEMENT f-7 �« <br /> i Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I g—&able Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing / __`�_ „ •,_ •.___•____•.__ <br /> Domhstic%public I Driven Gauge of Casing / <br /> rrigation ! Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout --^ <br /> Disposal Other Other Information <br /> "Geophysical Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> i <br /> PUMP REPAIR: t . •A r__-/�/ State. Work.Done <br /> - - — <br /> DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br />'i 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 GROTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W PLOT PLAN 'ON RE ERSE SIDE) -� ` 1, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .. �• DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I,11/FINAL INSPECTION <br /> INSPECTION BY DATE -� INSPECTION B DATE <br /> 3/76 2M <br /> E H 1426 Rev, 1•-74 j <br />