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SAN JgAQUIN FOCAL HEALTH DIS <br /> FIlk <br /> FICE USE: /1601 E. Hazelto TRIGT <br /> n Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7(-p 9iQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��_76 <br /> (CompleCe In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pet'mit 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 ,1 :B d N A 41 ��d <br /> CENSUS TRACT <br /> Owner°s Name <br /> !^ ` Phone <br /> Address g ` (P41,1 /6 X City sa/ri4-1r <br /> Contractor's Name <br /> License #���one <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/-7 RECONDITION /_7 DESTRUCTION %f <br /> PUMP INSTALLATION PUMP REPAIR PUMPREPLACEMENT' l% r <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WEL <br /> INTENDED USL PUBLIC DOMESTIC WELL <br /> E TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Gable Tool Dia. of Well Excavation <br /> Domestic/private Drilled <br /> ,._�. Dia. of Well Casing �(,`y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth` of Grout Seal, <br /> Cathodic Protection Rotary a of Grout 4 <br /> Disposal Other Other Information <br /> Geophysical ---- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Hone <br /> PUMP :REPAIR: L-7 State Work DoneCAL _ f d�— <br /> ee6 44" <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and procedure Approximate Depth �lJ <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 true to the-best of m knowledg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AN A FINAL INSP CTIO <br /> SIGNED -- ,f TITLE <br /> P T FLAN ON ERSE SIDE <br /> PHASE I % FOR DE TMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHAS FINAL INSPECTION <br /> INSPECTION BY i DATE INSPECTION BY <br /> -- e DATE _ - <br /> E H 1426 Rev. 1-74 <br /> - _ 1-76 9M <br />