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C ryt�6 1� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOF­�OFP.Z'C USE: 1601 E. Hazelton Ave. , . Stockton, Calif. <br /> Telephone : (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ./0-7-7 <br /> (Complete .In Triplicate) <br /> Application is hereby made Jj;the San Joaquin Local Hea.lth. 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 the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - _. � /� �, � CENSUS TRACT <br /> Owner's Name '�� 6-7-f Phone j <br /> �. <br /> Address - "V <br /> Contractor's Name ! License �ff93-7ahone <br /> �. -74 G <br /> TYPE OF WORK (Check)': NEW WELL / / DEEPEN/_/ RECONDITION FT DESTRUCTION /-7 <br /> PUMP .INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other / f <br /> DISTANCE TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPF-PTY� LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL p , <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia, of- V611 Excavation <br /> X Domestic/private I Drilled Dia. of Well. Casing <br /> Domestic/public 1 Driven Gauge of Casing , <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal {1 Other a Other Information <br /> Geophysical _ 'Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor �. <br /> Type of': Pump / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> State Work Done --�- � <br /> DESTRUCTION OF WELL: Weil Diameter Approximate Depth <br /> Describe Material and' Procedure _ N <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 I� <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 know d .e and elief. I WILL CALL FOR A GROUT,INSPECTION j <br /> PRIOR TO GROU INC AN A FINAL I E "16-IO , <br /> SIGNED ITLEf', <br /> (D W PL P AN ON R RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL COMMENTS: 1 " <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �� � DATE <br /> 1 <br /> E H 1426 Rev. , 1-74 2M o!/7 _ <br />