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Id SAN JOAQUIN LOCAL HEALTH DISTRICT <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. 6-z>7*P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -s#-77 <br /> (Complete In Triplicate) <br /> Application is Lereby 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 /> Count Ordinance No 186 aid t}�� Rules d Regulations of he San Jgaquin Local Health District. <br /> �,2 � O T fit{ ���� &'6;?e� ENSUS <br /> JOB ADDRESS/LOCATION TRACT <br /> Owner's Name �' �� Q Phone �, <br /> �J i <br /> Address ✓ -� -� Ci <br /> Contractor's Name Licens-XI 3 3Phon&4 <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN %/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP 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 (n <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 0 <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 1 H.P. <br /> PUMP REPLACEMENT: 47\ State Work Done <br /> PUMP .REPAIR: / / 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 /> 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING .AND A FINAL INSPECTION. <br /> SIGNED TITLE ter✓ <br /> V ( 4DRAW PLOTPLAN ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE S �/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEI I/ INAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY ATE -7 <br /> E H 1426 Rev. 1-74 I"'"�` �^ FORM Sr��', 376 2M <br />