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SAN J UIN LOCAL HEALTH DISTRICT <br /> "7E O�E:CE ,USE: 1601 F. ReYelLon Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUuTION OR PUMP PERMIT Permit No,�C,— <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9 <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 Jcsyuin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION It', �r �« t r 'y��;.cc 'JI. !) / < (�[ CENSUS TRACT <br /> Owner's game Phone <br /> Address ..Z 3 f ")1 -f R r City xJ=f— <br /> Contractor'a Name �'-t L -_ — License I/(, 7 .3 Phone_k, , <br /> i <br /> TYPE OF WORK (Check): NEW WELL /% DEEPEN /7 RECONDITION /7 DESTRUCTION L7 <br /> PUMP INSTALLATION /7 PUMP REPAIR fi�—PUMP REPLACEMENT /? <br /> Other <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 CO STRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Doft"ticlpublic - Driven Gauge of Casing <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: v <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done + p <br /> PUMP REPAIR: State Work Done j_t('t <br /> DESTRUCTION OF WELL: Well Diameter Approxisate Ntpth d <br /> Describe Material and Procedure - \ <br /> I hereby agree to complj with all laws and regulations of the San Joaquin Local Hea ch 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 trueo the best of my knowledge and belief. I WILL CAI .-FOR A GROUT INSPECTION <br /> PRIOR, TO G OUTING AN A FiINAL.7 PECfION. ) <br /> SIGNED - T C —2-,-`-- TITLE ✓/�✓ rL/ <br /> I-IDRAW _PI&T PLAN ON R SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHA`,E I ­17- <br /> APPLICATION ACCEPTED BY d DATE <br /> ADDITIONAL COMMENTS: <br /> PEASE II GROUT INSPRCTTOW PHASE III FINAL INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY DATE F / , e <br /> 3/76 2H <br /> E H 1426 Rev. 1-74 <br />