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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ;1601 E. Hazelton Ave. , Stockton,' Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2k'z_'-—2-4 W <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued i -3e-7.6 <br /> .S?`� a (Complete In Triplicate) <br /> Application is hereby tnadeVtn the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is wade in compliance with 'San Joaquin <br /> r <br /> ` County,, Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> t 1 <br /> JOB ADDRESS/LOCATION � CENSUS TRACT OS( -f e-ocv-Z,!� <br /> Owner'a Name G � <br /> Phone <br /> r <br /> Address A7 4) ,, <br /> City . <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN /? RECONDITION /? DESTRUCTION �f 4 <br /> PUMP INST TION/ / PUMP REPAIR '/� PUMP REPLACEMENT 17 �y <br /> Otherl/ ff — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PI <br /> T PRIVY <br /> SEWAGE DISPO AL 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 y Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing m1 <br /> Irrigation a Gravel Peck Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1-9 <br /> Disposal A Other _ Other Information j <br /> Geophysical Surface Seal Installed By: `!� w <br /> .PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT / / State Work Done <br />' <br /> PUMP ,REPAIR: <br /> State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth �I <br /> Describe Material and Procedure . . "�-`----~ <br /> I hereby agree to comply with-all-laws and regulations of the San Joaquin Local. Health District f <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 belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO G TNG - . DIA;VI INSPECTION. <br /> SIGNED �- , E�. _ _ <br /> TITLE <br /> ( W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ByDATE <br /> ADDITIONAL-COMMENTS: 4 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE „ . INSPECTION BY _45 , . DATE ' <br /> E; H 1426 Rev. 1-74 <br />