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SAN JOAQUIN LOCAL 'REALTH DISTRICT <br /> _F0K;VOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -�'4"71 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the les and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I� �! ® Y c:zT CENSUS TRACT ^ <br /> �' <br /> Owner's Name ee / Phone <br /> Address I�I City <br /> Contractor's Name ILicense <br /> Phone d <br /> TYPE OF WORK (Check) : ' 'NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /77 <br /> Other / / _ V) <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOS FIELD�`� - CESSPOOL%SEEPAGE FIT.- OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE : TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ` Industrial 3 Cable Tool Dia.,.of-, Well Excavation Ile <br /> T Domestic/private;, Drilled Dia. of Well Casing <br /> Domestic/public ] Driven ` Gauge of Casing /Z <br /> Ir"rigat3on ' `°- Gravel Pack Depth of Grout Seal f� <br /> Cathodic Protection Rotary Type of Grout _11 _ <br /> k Disposal • '.� t. .~ Other Other Information <br /> ( Geophysical F .. _ -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ea-c A-, 7 � <br /> 'Type of Pum <br /> ' 4 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> i <br /> DESTRUCTION OF WELL: - Well Diameter Approximate Depth <br /> - ----- ------ - <br /> : Describe Material and Procedure <br /> I hereby agreeyto 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 DA�S <br /> after completion of my, work n a new Well, I will furnish 'the San Joaquin Local Health Distriet a <br /> WELL DRILLERS REPORT of a"best <br /> nd notify them before putting the well in use.. The above <br /> information is *tru o° the my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ,GROU E951, 0N. <br /> SIGNED `' TITLE <br /> �I. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ' I n FOR DEPARTMENT USE ONLY <br /> PHASE I !I q <br /> APPLICATION ACCEPTED BYA-"U- DATE �-g <br /> s ADDITIONAL COMMENTS: :I1 <br /> PHASE II?IGROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BYNA DATE VINSPECTION BY DATE a.-a-j-`1 <br /> 2M =rt <br /> E H 1426 Rev. 1-74. : 1177 <br />