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A4/1601 E. Hazels r SAN JOAQUINLOC111 HEALTH. DISTRIC,T�FOL OFFICE USE: Ave, StocktonCalif. <br /> Telephone : (209) 466-6781 { <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nol, Z � <br /> S <br /> THIS PERMIT EXPIRES 1 YEARf <br /> FRlM ATE ISSUED Date Issued �2 a��6 <br /> A (Complete In Triplicate) <br /> pplication is hereby made tolthe San Joaquin Local Health District for a permit to construct I <br /> and/or install the work herein described. This application isimade in compliance with San Joaquin' � <br /> County Ordinance No. 1862 and the Rules and Regulations- of the San Joaquin Local Health District. <br /> I � <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone a.� i <br /> Address Cit <br /> y - dx d— " <br /> 71 <br /> Contractor's Name r <br /> License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other /_/ <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINFS2-00 PIT <br /> SEWAGE DISPOSAL FIELD 2Q67-1- 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 RDia. of Well Excavation <br /> Domestic \ <br /> t� <br /> /private i/brilled Dia. of Well Casing v , <br /> Domestic/public I Driven Gauge of Casing <br /> Irri ation - --- <br /> g .Gravel Pack Depth of Grout Seal <br /> Cathodic-'Protection Rotary Type of Grout <br /> Disposal . _- Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALION: �tractorG <br /> Type oft: Pump 9 H.P. <br /> PUMP REPLACEMENT: C <br /> State Work Dane <br /> PUMP .REPAIR: F / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 'l <br /> Describe Material and Procedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the 'San Joaquin Local Healthy District i <br /> acid the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS 4 <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 notifythem before eputting 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 G OUTING AN2,,A F4NAL INSP CT ION , I — I A <br /> SIGNED TLE <br /> T DRAW <br /> PHASE IFOR DEPARTMENT USE ONLY / <br /> .�L / <br /> APPLICATION ACCEPTED BY k1 DATE ��- �7_. . <br /> ADDITIONAL COMMENTS: 11 <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 3- b <br /> E H 1426 Rev. 1-74 /�.�CGr�r� / %2�r �� ' wra.�O' . _. /.V,2 7/76, /76 <br />