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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: �,Id <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-,6—oza.) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /_,1/- 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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules andegu ations of the San Joaquin Local Health District. <br /> - mel <br /> JOB ADDRESS/LOCATION f�r- CENSUS TRACT <br /> Owner's Name - lz&l/1 -- _ Phone <br /> Address �p <br /> Contractor's Name �,�iZ.vG�/©Y� License # Phone2420 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN%/ RECONDITION / / DESTRUCTION QX <br /> PUMP INSTALLATION /—/ 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 WELL PUBLIC 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 l it <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <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 Deptb 14310 <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and r gulatio s 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 GROUjqG AN A F;k INSPECTION. . <br /> SIGNED TITLE<iy! y� ,�n <br /> WI'WPL T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IA G NSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BYj DATE INSPECTION BY DATE <br /> 376 2M <br /> E H 1426 Rev. 1-74 ' <br />