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_ f�ilJ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. :�L- ,��Ld <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) d <br /> Application is hereby made to the San Joaquin Local Health District for a permit to codstrudt p <br /> and/or ,install the work herein described. This application is made in compliance with San. Joaquin ! <br /> County Ordinance No. 1862 and the Rules and lations of e San Joaquin Local Health "District. <br /> JOB ADDRESS/LOCATI N Q CENSUS TRACT <br /> Owner's NameZe�� <br /> Phone 's . <br /> Address `C Q City �� � 6.� ]� <br /> Contractor's Name <br /> N71 Licensejl D`�Phone <br /> TYPE OF WORK (Check) : NEW WELL /Vf.---DEEPEN / / RECONDITION_/ ./ DESTRUCTION /? <br /> PUMP INSTALL1i0N / SUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK,�� SEWER L�NES Q IT PRIVY <br /> SEWAGE DISPOSAL FIELD ,":�-�CESSPOOL/SEEPAGE PIT OTHER --� <br /> PROPERTY LINE '7- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE "TYPE OF WELL CONSTRUCTION SPECIFICATIONS . Vf <br /> Industrial Cable Tool Dia. of Well Excavation <br /> --,'tomestic/private 7Drilled Dia. of Well Casing <br /> Domestic/public -;r Driven Gauge of Casing <br /> Irrigation 1, Gravel Pack Depth of Grout. Seal 1�1-0 <br /> Cathodic. Protect ntary � - T_ypa,,of�Grout <br /> r _ Disposal-� l Other tile Other Information ' <br /> Geophysical Surface Seal"Installed B <br /> e <br /> PUMP-'INSTALLATION: t Contractor <br /> -. Type of Pum H.P. <br /> PUMP REPLACEMENT: / /,L State Work Done (_ <br /> PUMP-.REPAIR:-- -/. /—State Work Done fR'c- - <br /> DESTRUCTION OF WELL: WellrDiametera/ L{•Je/, Approximate Depth <br /> Deg;cribe4 Mateiial and Proce.du-re'`' <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 /> WEL RILLERS REPORT of the well and notify them before putting the ..well in use. The above <br /> info ion is true to e b my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTING AND A FI I P C N. -�� <br /> SIGNED - _ ' 1 TITLE <br /> DRAW- PLT PLAN ON REVERSE SI E) <br /> ¢ 4- /FOR DEPARTMENT USE ONLY <br /> op <br /> AP CCEPTED BY DATE <br /> ADDITIONAL COMMENTS: w <br /> PHASE GROUT IN N .' PHAS III IN INSPECTION <br /> INSPECTION BY DATE � ��INSPECTION BY DATE <br />� 3/76 2M <br /> E H 1426 Rev. 1--74: <br />