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MAIL " ' � 5 - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 6"e �vf1`S S y k5` -- <br /> r, USE: 1_601 E. Hazelton Ave. , Stockton, Calif. -73Z" �• 0&eefi d/ <br /> Telephone: (209) 466-6781 ego <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> JAN 16 1978 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Q141PAI X /� CENSUS TRACT <br /> Owner's Name MAR Yi Z f� d Phone. — 3 <br /> Address _ S tez City T- <br /> Contractor's Name (9y e X/License # Phone <br /> { <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN _/ RECONDITION /_/ DESTRUCTIONr— <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT/-7 Ori <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY <br /> SEWAGE DISPOELD C S <br /> SAT. HSPOOL/SEEPAGE PIT OTHER Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation q% <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 5 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4 idNeoC <br /> Type of Pump r H.P. / - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REP _ / / State Work Done �Il <br /> DESTRUCTIAN OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Pr cedure <br /> 1 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 we'll 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 G U NG AND A FINA ECT ION. <br /> SIGNED TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE �r�- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHPSE T. '/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> T `G , <br /> ' x!77 2M <br /> E H 1426 Rev. , 1-74 .. <br />