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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE E: i 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' p� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-s^—&--/-5;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 /> F County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION mh,'„ 4f �6 z _ CENSUS TRACT ` <br /> Owner's Name Phone ` <br /> Address • SN�©Q E F i/ip-,n6n- ]' City <br /> Contractor's Names License iPjS� Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/X/ DEEPEN/ / RECONDITION / / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWEIR LINES 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 /> I Industrial Cable Tool Dia. of Well Excavation F `• <br /> j Domestic/private. Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal O � <br /> Cathodic Protection" �� Rotary Type of Grout .� $.. <br /> Disposal Other Other Information' �l <br /> Geophysical Surface Seal Installed B d •^4. 7 <br /> PUMP INSTALLATION: Contractor `. <br /> Type of Pumps H.P. 3 <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 before putting the well in use. The above <br /> inf�RTO <br /> t on is t to t e best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> pR A NAL IN P ION. <br /> SI 6 TITLE pb,r rJt , <br /> (DRAW MT PLAN 'ON REVERSE SI ) � ' <br /> FOR DEP TMENT USE ONLY <br /> `PHASE I � �J <br /> APPLICATION ACCEPTED BY /L�� DATE <br /> ADDITIONAL COMMENTS: <br /> P PHASE II GROUT INSPECTION P IIZ I_NS ZC�ON <br /> INSPECTION BY - DATE <br /> V-ts INSPECTION BY TE <br /> —f <br /> E H 14263/76 2m <br /> Rev. 1--74 <br />