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//// SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 4601 E. Hazelton Ave. , Stockton,' Calif. <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No: ?3/ <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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 &• VQ Al C /PlAl CENSUS TRACT <br /> Owner's Name .�� eC'v Phone V a��J`?�j� <br /> Address ZO 03 IV .. , Pi k City 1s,gALv,a <br /> Contractor's Name License <br /> 4aE4�AOa Phone .s_ 7 <br /> _ it <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I <br /> Other / / <br /> DISTANCE TO NEAREST; `' SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL + <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \.I <br /> Industrial r Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing � I <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth' of Grout Seal V <br /> Cathodic Protection Rotary Type of Grout <br /> N <br /> Disposal Other Other Information ' ` <br /> Geophysical Surface Seal Installed By: <br /> --- I <br /> PUMP INSTALLATION: Contractor c�\ <br /> Type of Pump H.P. �3 <br /> (� I <br /> PUMP REPLACEMENT: iS�/ State Work Done <br /> R ; <br /> PUMP .REPAIR: / / State Work Done JJ' <br /> I <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 E <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 1 <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 I <br /> PRIOR TO G5RUTING D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> 7blaw- PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSVECTION. PHASE I/F1,NAL INSPECTIPjj, <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426Rev. 1-74 <br /> 3/76 2M <br />