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lSAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 465-6781 d4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��-JP*gp <br /> THIS PERMIT EXPIRES 1 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 � LD�- � �� � CENSUS TRACT <br /> Owner's Name 1C V. � Nt' ` - - - Phonec;Z3 - -30 <br /> Address � �J �,�c�. `!J`� e _ City vza <br /> r <br /> Contractor's Name �-� �;� �i License Phone - <br /> i <br /> TYPE OF WORK (_Check) : NEW WELL /_7 DEEP / J 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'DOMES TIC-WELL-"=--"MPUB-1,C DOMESTIC :WELL- <br /> INTENDED USE _ TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial _f., `-­Cable'Tool-,; Dia. of Well Excavation <br /> Domestic/privateMDrilled Dia. of Well Casingf <br /> Domestic/public Driven Gauge.yof_Casing <br /> Irrigation'r' + Gravel Pack Depth of Groin Seal <br /> Cathodic Protection Rotary_..:.,,_..:„_ Type of-Grout- �- �- <br /> Disposal ,_._ ,�__.._ _ Other;. Other Information <br /> Geophysical Surface Seal Ittstal]ed B <br /> � I <br /> PUMP INSTALLATION; f{Contactor - - ; <br /> Type `of•=Pump E <br /> PUMP REPLACEMENT: / / 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 �be'fore.,putting', the well in use. The above <br /> information is 'true to the bes-t., of my-knowledge and bel-iof. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO g-9OUTING4Qa FINAL INSPECTION. i <br /> SIGNED TITLE7 7; <br /> DRAW4'L T PLAN 'ON REVERSE SIDE) <br /> R DEPART'MENT--U.SE-.ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r' DATE Via. <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT rINSPECTION-, P S /FIN NSPECTION !7& <br /> INSPECTION BY l'pATE� INSPECTION BY ATE -- <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />