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' a Gc 4 A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> WF�.OFF CE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 7-f 2L <br /> {; (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construt-9t,` • <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 0./ CENSUS TRACT <br /> Owner's Name ?rj G tGl A1J F Phone , <br /> Address <br /> �. City . <br /> Contractor's NameLicensePhone 76 <br /> ... `. <br /> y <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN-/7 RECONDITION /7 DESTRUCTION /7 <br /> /�7� <br /> PUMP INSTALLATION PUMP REPAIR/7 PUMP REPLACEMENT JLC <br /> Other /_7 ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL- PUBLIC DOMESTIC WELL <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 <br /> . - - Surface Seal Installed By- <br /> PUMP <br /> INSTALLATION: Contractor �...�.� J ►',ml <br /> Type .of Pump � /�ZAy i �,� H.P. / <br /> ' <br /> PUMP /TITState Work Donev/ rpe _►teta <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 anew 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..knowl dge d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU INC AND A FINAL INSPE <br /> SIGNED . , ITLE 6 <br /> (D*W_jPM LAN DN REV E SIDE)- <br /> ' <br /> OR DEPARTMENT USE ONLY <br />; PHASE I <br /> APPLICATION ACCEPTED BY DATE: <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 -1 - -- 4/75 2M <br />