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3 SAN J'OAQUI+4� 1,0C .L HEALTH DISTRICT <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;> 7�6 <br /> P (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i and/or install the work herein described. This appXication .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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i . <br /> Owner's Name I�: Phone ' — 9 <br /> �I f � <br /> Address City <br /> Contractor's Name IG License # . 1jjj?aV Phone , 1�f 6-70 <br /> TYPE OF WORK (Chetk): NEW WELL -a DEEPEN J RECONDITION /T]" DESTRUCTION % f <br /> PUMP INSTALLATION/-/ PUMP REPAIR/-7 PUMP REPLACLMENT 17 <br /> other /7 <br /> . <br /> II' <br /> DISTANCE TO NEAREST:`-SEPTIC TANK SEWER LINES 45� PIT PRIVY <br /> t SWAGE DISPOSAL FIELD 5�' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY 'LINE °- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL a <br /> INTENDED USE i T-TYPE. OF-WELL *'I CONSTRUCTION SPECIFICATIONS �# <br /> Industrial Cable Tool ''' ' Dia. of Well Excavation, <br /> _ Domestic/private Drilled' * :Dia. of Well Casinig .2 r V <br /> Domestic/public 'Driven Gauge of Casing" <br /> Irrigation :'; Gravel- Pack `' Depth of Grout`Seal <br /> Cathodic Protection Rotary V ` Type of-Grout (7,0 ,, a4t; „ <br /> Disposal Other Other�Information <br /> Geophysical - �..-�. 4 Surface Seal Installed By: <br /> PUMP INSTALLATION:' Contractor <br /> . Type .of Pump <br /> PUMP REPLACEMENT: % / State Work Done > '' r ,. <br /> M <br /> F FUMp REPAIR: �%� State Work Done �.'.'�"° �'. <br /> DES-TRUCTION OF WELL: i Well Diameter T ' <br /> C Approximate'Depth...._.� J <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 khe 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 -FORA GROUT INSPECTION <br /> IPRIOR TO GROUTING 'AND AI;kNAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> S FOR DEPARTMENT USE ONLY <br /> PHASE I $ - , <br /> APPLICATIONYACCEPtt:b BY.1 t,; DATE Z 6 <br /> ADDITIONAL COMMENTS: iI I I . <br /> PHASE II GROUT INSPECTION PHASE l _I_II/FINAL INSPECTION INSPECTION BY�"'~'`' ',' r "DATE INSPECTION BY ,. DATE <br /> E S 1426 Rev 1�-74 r, 4/75 2M <br />