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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo-R OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP PERMIT Permit No. <br /> THIS.-PERMIT EXPIRES 1 YEAR FROM DATE_ ISSUED Date Issued 1-/,2-77 <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 /> 4� <br /> r <br /> 'JOB ADDRESS/LOCATION j --ly - G ll ,_ CENSUS TRACT <br /> Owner's Name r �. ✓�" �I s �, s -- -- Phone <br /> Address �i L L <br /> City ✓ � c�t <br /> Contractor's Name /��v�- '! ,�� c: � i G License #1� 0 PhonLw � �y <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN '/7 RECONDITION /_7 DESTRUCTION F7 <br /> PUMP)iNSTALLATION /—/Z_ UHP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC- TANK SEWER LINES PIT PRIVY <br /> SEWAGE,. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ' <br /> Industrials Cable Tool Dia. of Well Excavation (" <br /> _y Domestic/private II,� Drilled Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1- Rotary Type of Grout <br /> Disposal A Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION., Contractor <br /> Type;`of Pump H.P. j z <br /> x PUMP REPLACEMENT: / / , State Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> .., .. t� !I tfIJAA6�QCJd1 <br /> J)E5•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 /> l WELL DRILLERS REPORT of the:well and notify them before putting the well in.use.. The above <br /> f information is true to the-b'est ofmy knowledge and belief. I WILL CALL FOR A ,GROUT INSPECTION P <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED y TITLE <br /> I DRAW PLOT PLAN ON REVERSE SIDE <br /> �I FOR DEPARTMENT USE ONLY <br /> kPHASE I <br /> APPLICATION ACCEPTED BY DATE Z Z:f Z <br /> ADDITIONAL COMMENTS: t L <br /> PHASE II GROUT 'INSPECT30N PHA III F NAL INSPECTION <br /> INSPECTION BY !"DATE INSPECTION. BY DATE 7�7 - <br /> �; j E H 1426 Rev. 1-74 1-74 2M <br />