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L' SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7,Z,,267 <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z-LL-Z,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 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 CENSUS TRACT <br /> Owner's Name f Phone 16 Z-4 0 a 0 <br /> Address 4 '7 City <br /> Contractor's Name ,� � License 1410 z3?3 Phone36? 3 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN / / RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION / / _ <br /> PUMP REPAIR fs PUMP REPLACEMENT /-7 <br /> Other /-7 <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 V <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 y� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Dona <br /> DESTRUCTION OF WELL: . Well .Diamerer Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with-- - <br /> all Taws 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 ue to the - st of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G D A AL INSP ION. <br /> SIGNED TITLE <br /> 711 <br /> DRAW PL T PLAN ON RE FRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3- [[- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �' <br /> ,,E H 1426 Rev. 1-74 <br /> 3/76 2M <br />