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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: L>'� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 V4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J 6-t/q 3 P <br /> y THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-//-76 <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. 1 G2 dSbl-- Rules and Regulations of the San Joaquin Local Health District. _ <br /> 07 <br /> (P/,-? �P <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Name Phone j/- jss 7 <br /> Address ® City <br /> Contractor's Name �ti��vV� License # f�� 7� Phone 9L� <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN '/-7 RECONDITION /-7 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 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 Surface Seal Installed By: V <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. rr <br /> r h <br /> PUMP REPLACEMENT: /✓/ State Work Done_ . %Z <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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED n_m= TITLE <br /> W.. PLAN 'ONREVERSE SIDE) K i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY j DATE CJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE UIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,�is <br /> 3/76 fit. <br /> E H 1426 Rev. 1-74 <br /> .�-�. <br />