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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` FORtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_6 Z) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> (Complete In Triplicate) ?moo q - 0&0-- <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 and Regulations.of -ihe San Joaquin Local Health District. <br />` JOB ADDRESS/LOCATION2. ' '�' r _ , ..: ) jj CENSUS TRACT <br /> Owner's Name i Phone <br /> Address City <br /> Contractor's Name License <br /> GZ Phone° yG.t�s,�g. N <br /> w <br /> TYPE OF WORK (Check) : NEW -WELL /? DEEPEN -/? RECONDITION /-7 DESTRUCTION _f_7 W <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT 1-7 rn <br /> Other / — �+•` �� 1 ' ,,. <br /> DISTANCE TO NEAREST: SEPTICITANK 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 I Cable Tool s_ . Dia. of Well Excavation <br /> Domestic/private } . Drilled Dia. of Well Casing <br /> Domestic/public Driven_. <br /> - GaugeofCasing,,. <br /> Irrigation I 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 o£ Pump i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> s <br /> PUMP '.REPAIR: /? State Work Done <br /> ti <br /> ES-TRUCTION 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---and helief.-I WILL-CALL -FOR-A'GROUT 'INSPECTION' <br /> PRIOR TO 0 TTIXRegk A LNAI: ASPECTION. <br /> SIGNED fi C_F <br /> "• ' . TITLE"- <br /> - ' (DRAW PLOT PLAN ON REVERSE' SIDE <br /> x <br /> FOR DEJURTNENT USE -ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED � � DAT S�'- 1p 7S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN EC N PHASE i FINA16 INSPECTION <br /> INSPECTION BY DATE ' w ! x INSPECTION BY DATE S <br /> s <br />; � E H 1426 Rev. 1-74 1-74 2M <br />