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r SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> f <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. z__2_f4,0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-I _.2 <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 A l`""'W 16,&L GJ j2 CENSUS TRACT <br /> Owner's Name Phone <br /> Address D l "� City d144_1 r <br /> Contractor's Name License IV6 L 3Phone 3�� T <br /> I TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /`J <br /> PUMP INSTALLATION/ / PUMP REPAIR /V PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i- PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE,- TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. ...- ._,.W .. 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 By: <br /> � PUMP INSTALLATION: Contractor <br /> Type, of Pump �. H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> s PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <br /> I hereby agree to comply with all laws andiregulations of the San Joaquin Local Health District <br /> k 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 i5-,true to the st of- ml-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G AD AL INSPE ION. <br /> SIGNED TITLE <br /> D W PL T PLAN ;ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY ~` r _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I F NAL INSPECTION <br /> F INSPECTION BY DATE INSPECTION BY DATE 6 2 <br /> :. � , .• 3/76 2M <br /> E H 1426 Rev. '1-74 <br />