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• JSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE-OFFICE USE: � 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: • (209) 466-081 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,2 <br /> THIS; PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued . /-ii-77 ` <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 Mork hereiindescribed. 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 /> .SOB ADDRESS/LOCATION�\,.� // f CENSUS TRACT; <br /> Owner's Name _IJ Z� _ Phone <br /> Address �$ � City .5e4d.,=Al ` <br /> 1 --- Contracte21 License <br /> Contractor's Name :1. ii; L. .' License #N6.276660 Phone ' � <br /> TYPE OF,WORK (Check) :- .NEW WELL '/.7 .DEEPEN / / 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 /> PROPERTYi LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation v � <br /> Domestic/private Drilled Dia. of Well Casing <br /> i Domestic/public I Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal 4. Other Other Information ' <br /> Geophysical. f' Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> t <br /> DESTRUCTION OF WELL:" Well:'Dl metier -Approximate Depth----7',.. '� + <br /> Describ'e 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 rue to the best of ,my'_knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO O G AN F14LI.'I, SP ION. <br /> SIGNED `"' ' ti. TITLE <br /> i a DRAW PLOT' PLAN ON REVERSE SIDE) A. ; <br /> j FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IjAWT SPkCTION PRASE I/F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> { <br /> 3/76""2M <br /> E H 1426 Rev. 1--74 ,, <br />