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JVD` SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICMlUgfE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 4 31P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 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. 1.862 and the Rules and Reg lations of the San Joaquin Local Health District. <br /> 5 &-#.t* CENSUS TRACT <br /> JOB ADDRESS/LOCATION �+ Y �� w � '� i �a*, <br /> Owner's Name Phone <br /> Address lei Q /Y City 4 <br /> Contractor's Name �$a.G� <br /> License # IY3 7hC—Phone 76% <br /> IL <br /> TYPE OF WORK (Check) : NEW WELL / 7 DEEPEN /_/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O► <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 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 i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /Xl 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 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- nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND A FINAL 1ASE0 . <br /> SIGNED TITLE <br /> W P T PLAN ONItffRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE y� 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ` PHASE IU N4zkNSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />