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- SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: !x'1601 E.. Hazelton Ave. , Stockton, Calif. 3 <br /> Telephone: (209) 466-6781 r 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 27-.a 93 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedl�t 9_�7 <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 /> J08 ADDRESS/LOCATION 2q713 -¢ CENSUS TRACT <br /> Owner's Name TA _ Phone X39 <br /> Address 3 City ` � C. o,U <br /> Contractor's Name %�, iJ , ; License # PhonegL � ?v <br /> # �f <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN '/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION ( PLUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERrLINES 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/publid Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary , Type of Grout <br /> Disposal Other lather Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , U p <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> t <br /> k PUMP .REPAIR: /—/S.ta.te._Wo.r-lc Dore, <br /> DESTRUCTION Of WELL: Well Diameter, Approximate Depth <br /> Describe Material and Procedure <br /> �i <br /> I hereby agree to comply with 'all laws and regulations of the San Joaquin Local Health District <br /> hand the State�,of Calif"orn a. pe'r.iaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion ofrmy wor.0 on 4a\new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRiLLBRS' REPO�RT�Of the well and notify them before putting the.-well. in use. The above <br /> inf-6r"matioiii` sCtriie to the;bes-tJof myknowledge and belief. I WILL--GA-=-MR A_GROUT,INSPECTION <br /> PRIOR TO GROWING AND A4-INA INSPECTION. <br /> SIGNED TITLE <br /> { .(DRAW PLOT PLAN ON REVERSE SID9) 1 <br /> FOR DEPARTMENT USE ONLY <br /> . PHASE I <br /> APPLICATION ACCEPTED'BY­ DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE./1GROUT,-INSPECTION PH&SA UI/WALIN5PECTIjDN <br /> INSPECTION BY DATE. INSPECTION BY DATE72 <br /> Z <br /> ---E H 1426 Rev. 1-74 ._. <br />