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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO) .OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> rZ4 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _1 .25-71 <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. 18b2-and, the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION F Q _ Qn p CENSUS TRACT 2`E4-02-0--6S <br /> Owner's Name C C Phone 4 _ <br /> Addressf� aJ !rde, tel City <br /> r' <br /> Contractor's Name LI Q License # .__)Z ` hone ' <br /> TYPE OF WORK (Cheek) : NEW WELL/ / DEEPEN / / RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <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 I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 11 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal I Other Other Information :O <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: "/ State Work Done t , i, r <br /> r I <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> . s <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 INSPECTION <br /> PRIOR TO GRO NG AND A FyqAL IIN PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) r <br /> PHASE I <br /> .-FOR DEPARTMENT USE ONLY <br /> .• � . <br /> APPLICATION ACCEPTED BY �, DATE <br /> ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASE +I/FINAL INSPECTION1 <br /> INSPECTION 'BY DATE INSPECTION BY DATE r <br /> l E H 1426Rev. 1-74 y -- ��7� - 2 <br />