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C, V'' SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> TOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;2-R-2,7 <br /> (Complete In Triplicate) o�3-r02.o !� <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 I <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB- ADDRESS/LOCATION / y�pus�v_ Un S� r��m�'ktr�a � Tr . .{c✓o CENSUS TRACT <br /> Owner's Name ~� <br /> C.J �� �� �' Phone <br /> Address 40(f oC City <br /> Contractor's Name License # Zj,3�id-_Phone - i-]6 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN"/ /. RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other <br /> s <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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation J. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection, Rotary Type of Grout <br /> Disposal Other Other._,Iixformation <br /> Ceophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor <br /> Type of Pump y H.P. i <br /> V _ <br /> PUMP REPLACEMENT /7 State-Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 hell, 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 o€ my knowl dge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A FINAL INSPECTI N. <br /> SIGNED o��c® ITLE <br /> DRA PLAN ON R FRSE SIDE <br /> � ] FOR DEPARTMENT USE ONLY <br /> JPHASE I <br />'�1'fAPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE ,II , 9VWI98PtCTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY / / DATE INSPECTION BY DATE <br />,rE H 1426 Rev. 1-74 <br /> 3/76 2M <br />