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SAN JOAQUIN LOCAL-HEALTH DISTRICT F <br /> FORi'OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466=6781 p <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. 744- /gyp M <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued _2,2_1_z 7r� <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 hereim described. - This application ismade in compliance with San Joaquin; <br /> County g Ordinance No., 1862 a d, the Rule nd Re ul i of the San Joaquin <br /> uin Local health District, <br /> JOB ADDRESS LOCATION �J� � ��� � inn CENSUS TRACT . <br /> Owner P s Name - / <br /> . Phone <br /> Address ? City <br /> F s <br /> Contractor's Name License # / hone JL <br /> W?--7G <br /> j <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/_7 RECONDITION /7 DESTRUCTION -f-7 <br /> PUMP INSTALLATION _j/ PUMP REPAIR / / PUMP REPLACEMENT %7 r <br /> Other <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �l <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ^Q^' <br /> Industrial i Cable Tool Dia. of Well Excavation 0 <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal i Other �Other Information <br /> Geophysical `''Surface seal 'Installed"By <br /> PUMP INSTALLATION: Contractox �cl��� �- j �+ <br /> Type of Pumps H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP OREtWe: &I State Work Done <br /> E , ESTRUCTION 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. owled and-' lief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINALIINSPECT <br /> SIGNED TITLE <br /> (D ' W P)LOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PRASE I <br /> F APPLICATION ACCEPTED BY DATE D'� d <br /> r7 V/ <br /> f ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION % PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br />� `i E H 1426 Rev. 1-74 1-74 2M <br />