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Ca ng OAQUIN LOCAL HEALTH DISTRICT <br /> FOF4i0FF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -�, Telephone.: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2�-9s/ <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued -1-olV-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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> yk.ze '12-4CENSUS TRACT ZO/- � '"0 <br /> JOB ADDRESS/LOCATION I.- alk <br /> Owner's Name fe .. Phone <br /> C Yo"d <br /> Address dG? City <br /> Contractor's Name _ License �� /�= Phone � � <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -/-7 RECONDITION /? DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR /)(7 PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER b <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 /> o— " ' Gravel Pack Depth of Grout Seal <br /> Zirrigdti <br /> Cathodic Protection Rotary Type of Grout r <br /> . Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUNP,,.REPAIR: State Work Done <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 - rue to the beat of my knvwI d a and e I WILL CALL FOR"A GROUT 'INSPECTION <br /> PRIOR TO G D A F AL INSPECTION <br /> SIGNED <br /> DRAW PL 0 REVERSE SIDE — <br /> FO PARTMENT USE ONLY ¢ <br /> PHASE I <br /> APPLICATION. ACCEPTED BY DATE // 0 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I .I '� ',4E H 1426 Rev. 1-74 1-74 2M <br />