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SAN JOAQUIN LOCAL HEALTH DISTR ICT <br /> -FOE-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (_�)µ p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-/S 76 <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. 1662 and the' Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONJ E. G f— - CENSUS TRACT <br /> Owner's Name A Phone --�y`3� <br /> `Address S 'm 4 - City SCS C :J <br /> t <br /> Contractor's Name „ bs SOA) License #o219010 Phone 8'S9;,U07 <br /> TYPE OF WORK (Check).: --NEW- WELL /-7 DEEPEN /-7 RECONDITION 17 DESTRUCTION f 7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT f? <br /> Other / f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . .PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q , <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ - Industrial .___r___ Cable Tool. Dia, of Well Excavation <br /> Datnestic rivate <br /> /p Drilled Dia. of-Well Casing � <br /> Domestic/public Driven Gauge of Casing ^ <br /> 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 /> f <br /> PUMP REPLACEMENT: / / Stats Work Done <br /> PUMP !REPAIR: f / State Work Done ,� Q T y <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 well, I will furifish 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 GROUPING D A, FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATES <br /> ADDITIONAL COMMENTS: <br /> PHASE IL,& UT INSPECTION PHASE $ I FINAt INSPECTI N <br /> INSPECTION BY efV DATE INSPECTION BY4. ,. DATE <br /> E H 1426 Rev. 1-74 4/75 2M <br />