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41 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE. 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7Z- qo <br /> k THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date ,Issued <br /> (Complete In Triplicate) <br /> Application is he'reby' 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' Rule`s and Regulations of the San Joaquin Local .Health District. <br /> JOB ADDRESS/LOCATION CJ'0 �Qr del - CENSUS TRACT <br /> Owner's Name k1�- Q.�' Phone. <br /> Address 3dev , .P- Cityr <br /> Contractor's Name p , . � ! _ License # /j,?37J Phone V,(�f4�S <br /> I TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /? <br /> I PUMP:-INSTALLATION / / PUMP REPAIR IZ/ PUMP REPLACEMENT -7 <br /> Other] <br /> DISTANCE TO NEAREST: SEPTIC] TANK iSEWER LINES PIT PRIVY <br /> SEWAGE.- DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> r INTENDED USE ITYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dkae of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> 4 Domestic/public Driven Gauge of Casing <br /> Irrigation } Gravel Pack Depth of Grout Seal <br /> Cathodic Protection It Rotary Type of Grout <br /> Disposal i1 - Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contrlactor- <br /> Type;„of Pump H.P. <br /> a <br /> PUMP REPLACEMENT: / / State- Work Done <br /> µ �/ E /Wp <br /> 'PLINiP .REPAIR: - . % �/ State Work`Done <br /> DES-TRUCTION OF WELL: Wellt`:.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 worlJ on anew 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' TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 1 ._t moi, . l 4 ., iI TITLE <br /> I '°DRA T PLAN"ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T '.�• 0 72 �G <br /> APPLICATION ACCEPTED BY } r►+-�,� DATE <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GROUT,rN-S`PCCTIO14 V VPFOE <br /> I N INSPECTIO <br /> INSPECTION BY ''DATE INSPEC ION B TE <br /> r r . 3/76 2M <br /> E H 1426 Rev. 1-74 <br />