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SAN JOAQUIN LOCAL HE <br /> FOfi;O CE USE: � HEALTH DISTRICT <br /> 1603 E Hazelton Ave. , Stockton, Calif. <br /> Telephone:grt p (2:09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. 7s'_50Q")o <br /> THIS PERMIT EXPIRES 1 YEAR FROM- DATE ISSUED Date Issued1,-)-7-75' <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 ZS Of� d ®�, ? CENSUS TRACT <br /> Owner's Name e-0 ,e-j <br /> Phone ' <br /> Address <br /> City 1 r <br /> Contractor's Name License � - Phone <br /> TYPE OF WORK (Check): NEW•WELL /7 DEEPEN '/7 RECONDITION /�/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PW. REPLACEMENT /7 <br /> Other %7 <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 INT <br /> Ind USE �L'YPE SOF WELL COAiSTRUCTION SPECIFICATIONS \ � <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing "V <br /> Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other <br /> Geophysical Other Information <br /> Surface Seal Installed By: <br /> 1 <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump <br /> H.P <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> LUMP REPAIR: / State Work Done <br /> DES,�TRUCTION OF WELL:. Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 th fore Putting..the:.well. in.use..... ,The above <br /> information is true to the-best m <br /> Y o ge and belief. I WILL CALL F A GROUT INSPECTION <br />'RIOR TO GROUTING AND A PIN p 0 <br /> SIGNED <br /> 'ITLE <br /> (D W PLO PLAN ON RSE SIDE <br />?HAWSE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYi <br /> ADDITIONAL COMMENTS: DATE , /a-yl- <br /> _�„,_ <br /> PHASE II GROUT INSPECTION <br />[NSPECTION BY PHAS I FIN INSPECTION <br /> ATE INSPECTION BY + DATE j <br /> � D <br /> E H 1426 Rev. 1-74 . <br />