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SAN JOAQUIN LOCAL HEALTH DISTRICTS�� <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. -7 7 1 � <br /> Telephone: (209) 466-6781 <br /> O -[t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z?7,o91,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7.7- <br /> (Complete <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 /> JOB ADDRESS/LOCATION ` �CCri� _ /�;i CENSUS TRACT <br /> Owner's Name Phone ��r <br /> Address _ Zo 2F-2 � pcic�G City <br /> Contractor's Name [4Cc 2s` License � cT$� Phone/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELLff DEEPEN%/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR '/ / PUMP REPLACEMENT /_7 <br /> Other T-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -,OEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEXPPRIVATE DOMESTIC-WELL 42 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial Cable Tool Dia. of Well Excavation /"o <br /> Domestic/private Drilled Dia. of Well Casing �`V <br /> Domestic/public Driven Gauge of Casing r/ r /,60 G <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By:� � c.� _ <br /> PUMP INSTALLATION: Contractor /Z <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work-Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION 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 we11''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 REP of the-well and notify them before putting the .well in use. The above <br /> information is ue to . e-bes of my..knowledge and belief. I WILL CALL YOR A GROUT INSPECTION <br /> PRIOR T A F SP ION. <br /> SIGNED TITLE <br /> DRAW-P1 T PLAN ON REVERSE SIDE) <br /> F R DE T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT I SPECTIO SE I /FI INSPECTION <br /> INSPECTION BY DATE _�-\� - INSPECTION BY �—� DATEAT <br /> E H 1426 Rev, -1-74 ' <br /> 3/76 2M <br />