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t' SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> USE- <br /> FOR OFFICE USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) "466"6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -37V <br /> THIS -PERMIT EXPIRES I YEAR FROM DATE ISSUED Date IssuedWAR 15 1978 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 4 nsu.S' CENSUS TRACT <br /> Owner's Name Phone 3 <br /> l <br /> Address i City Z`�C.44i-/ <br /> Contractor's Name. J� c� dn/ License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /�/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/,!—PUMP REPLACEMENT- <br /> 0 the- <br /> r <br /> EPLACEMENTother / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRI <br /> EWAVY v <br /> GE DISPOSAL`FILD CESSPOOL/SL�"-EPACE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL__ _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing *� <br /> 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: <br /> PUMP INSTALLATION: Contractor <br /> ype of Pump r H.P, . <br /> PUMP REPLACEMENT: 4 . J / ;, State Work Done rn <br /> PUMP 'REPAIR;` ­ " <br /> / / 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 /> andwthe'"StatelofnCalif'ornia pertaining to or'—regulating well 'donstruction. 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 puttingthewell in use. The above <br /> information is true to the best of my knowledge and belief. I` WILL CALL FORA ROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL CTI N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �� FOR DEPARTMENT 'USE ONLY <br /> PHASE I q <br /> APPLICATION ACCEPTED BY ` "' <br /> • DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION i P SE INAL SPECTION <br /> INSPECTION BY DATE 4'7 1_e ,f s INSPECTION B DATES <br /> t <br /> E H 1426 Rev. • 1-74 n 2Ph � ! <br />