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Cav 16�-�Iza SAN JOAQUIN. VOCAL HEALTH DISTRICT <br /> iF0r,- OFFYCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> " Telephone ; (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> JAN Is 1978 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 'Date Issue <br /> (Complete In Triplicate) <br /> G, 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 CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address ?---d if/ ! City 1 . <br /> Contractor's Name ' License I a372-d_`Fhone �' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION AL / - <br /> _/ . DESTRUCTION / _ <br /> PUMP INSTLATION REPAIR 1� PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `, CESSPOOL/SEEPAGE PIT OTHER Q <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 /> x Domestic/private Drilled Dia. of Well Casing \Q <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 /> Type of Pump _ H.P. / <br /> PUMP REPLACEMENT: / /.. State Work Done <br /> PUMP .REPAIR: /)(/ State Work Done <br /> rDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1 Describe Material and Procedure <br />" <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 /> r 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 ahem before putting. the. well in use. The above <br /> " information is true to the best of my knowledgen`d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UT G AND A::FINA.L I CTI_0-V. <br /> SIGNED IfITLE _ <br /> /(DRAILOT' PLAN ON RVERSE SIDE) <br /> FO <br /> PHASE I R DEPARTMENT USE ONLY <br /> F APPLICATION ACCEPTED BY' DATE c� <br /> t. ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PAkSE /F INA14 INSPECT IO <br /> INSPECTION BYi _ DATE TNSPRCTION B ATE <br /> 2M <br /> E H 1426 Rev. • 1-74 <br /> bF�7.7 _ <br />