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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOE;OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-.a.2- y� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _�7 <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 compliance with San Joaquin <br /> ' County Ordinance No. 1862 and the Rulers /and Regula ions of the San again Local Health District. <br /> JOB ADDRESS/LOC x N <br /> CENSUS TRACT <br /> Owner's Na ~ > 8 67-6 Phone d'S� <br /> Address City <br /> Contractor's Name License/##�-37,5 Phoneme C7 OO- <br /> TYPE OF WORK (Check) : NEW WELL '/-7 DEEPEN I-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR .,) .PUMP REPLACEME9F /7 <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 <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP .REPAIR: 4 Z7 State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> (DRAW PLOT PLAN ON REVERSE SIDE) , <br /> PHASE I <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ,��� 7z � <br /> ADDITIONAL COMMENTS: �7--�--- <br /> PHASE Il GROUT INSPECTION PHAS I I/FIXAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 _ { 4/75 2M <br />