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c <br /> ® SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 7'1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G- 8'/" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S1 -7 <br /> (Complete In Triplicate) <br /> Application is hereby wade 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. 1$62 and the Rule and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION `�`— �dgZ I CENSUS TRACT <br /> Owner's Name 0"511v L� ~i v Phone <br /> 1 City�7D f <br /> Address <br /> Contractor's Name <br /> � Lam( j/ License 16V�'3�D Phon <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN / % -RECONDITION /-7 DESTRUCTION /? - — <br /> PUMP INSTAL/_/LATION / I PUMP REPAIR 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 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation X <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public 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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done a <br /> PUMP .,REPAIR: State Work Don /lzQ�e" f <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 TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> RAW PL T PLAN ON REVERSE SIDE <br /> (D <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �1"7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS ECTION PHAS I /FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE' <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />