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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OVI - E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedMAR 3 1978 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ! ► <br /> JOB ADDRESS/LOCATION A— y��� S T -- CENSUS TRACT <br /> Owner's Name p/eP,,L�/ Y AAA (J -r4,V _ Phoneri <br /> - F <br /> AddressCity <br /> Contractor's-Name License �� J� Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION jAt PUMP REPAIR/ / PUMP REPLACEMENT /7 �I <br /> Other / / — eK <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 j <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing j <br /> Domestic/public `; Driven Gauge of Casing i <br /> Irrigation Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection Rotary ' Type of Grout <br /> Disposal f ; Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Ql/C1/t/ <br /> Type of Pump Gr- H.P. 3 <br /> ,r <br /> PUMP REPLACEMENT: State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br /> i <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 INSPECTION <br /> PRIOR T GROUT G MD A F N NSPECTION. <br /> SIGNED y TITLE <br /> „ DRAW TL T PLAN 'ON RE FRSE SIDE) "'''I; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY A czed64DATE T <br /> ADDITIONAL COMMENTS: fF <br /> PHASE II GROUT INSPECTION PHASE,4ZI/FINA INSPECTION <br /> INSPECTION BY DATE =-- INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 . <br /> 3Yf a 2 ! <br />