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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 O/I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued E-34.27 <br /> J'}v (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 an Regulations of the San uin Local Health District. <br /> JOB ADDRESS/LOCATION G-u,riz�� CENSUS TRACT moo-- 0tt0---`;2 <br /> Owner's Name Phone <br /> 711 <br /> Address, C ` /C/C�. Cit <br /> y <br /> Contractor's Name License X14"ed", <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 t <br /> Domestic/private - Drilled Dia. of 'W-ell' 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 6 <br /> GeophysicalSurface Seal Installed B W <br /> N <br /> PUMP INSTALLATION: Contractor J <br /> Type of Pump ((}} H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 he best of my knowledge and belief. I WILL CA FOR A GROUT INSPECTION <br /> PRIOR TO G UTING INAL NSPE TION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 17 APPLICATION ACCEPTED BY DATE 0 —7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> bj/77 _ 2M <br />_ _ E--H .1.42-6. Rev. . 1-74 �. _ <br />