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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--,.2 . <br /> g'72 <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> IApplication is hereby made tis the San Joaquin Local Health District for a permit to construct <br />' and/or install the work herein described. <br /> This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �lZiW <br /> •rAWL �CENSU3 TRACT 00 r-oeo S� <br /> --f ) <br /> Owner's Name Phone <br /> Address , <br /> City 70 <br /> Contractor's Name LicenseN <br /> Phone 9-jy;71.h <br /> TYPE OF WORK (Check) : NEW WELL '/? DEEPEN '/7 RECONDITION �gr DESTRUCTION r7 <br /> PUMP INSTALLATION/ / a PUMP REPAIR '&7PUMP REPLACEMENT f f <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 /> x Domestic/private t� Drilled Dia. of Well Casing t <br /> t Domestic/public i Driven Gauge of Casing �. <br /> i'Irrigation 4 Gravel' Pack: Depth of Grout Seal <br /> J Cathodic Protection I Rotary Type of Grout <br /> Disposal - I Other I Other Information 3 <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor S Rim , . <br /> Type of Pump c� e - 1 Y <br /> A.P. Z e:; <br /> PUMP`REPLACEMENT: Ll State Work Done <br /> PUMP :REPAIR: State Work DoneS�_l/t'`!_C_ <br /> DE&TRUCTION'OF•WELL: Well Diameter Approximate Depth <br /> Describ�e 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 A FIN INSPECTION. <br /> SIGNED / <br /> _ TITLE -LSi�f�/t/ <br /> > (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY k DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> "..`_" <br /> E H 1426 Rev. 1-74 r ' 1, <br />