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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 7� 7 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;' 6 3&J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZ—/..5 2-6 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe <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 !�!/Ce�,c(e�.�a CENSUS TRACT <br /> Owner's Name �� r "'` Phone l 77— 4733 <br /> Address City <br /> Contractor's NameLicense 11,2 Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / J RECONDITION 4/ F DESTRUCTION /_7 <br /> PUMP INSTALLATION /x/ PUMP REPAIR/ / PREPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT .PRIVY <br /> SEWAGE DISPO FIELD CESSPOOL/SEEP�AdE. PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL _&_0 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 2- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grouter —��, <br /> Disposal Other Other Information <br /> —Geophysical Surface Seal Installed By: A,K. <br /> 4 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> PUMP .REPAIR: / / State Work Done i <br /> PES-TRUCTION OF WELL: Well Diameter Approximate Depth f <br /> Describe Material, and Procedure <br /> C <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californi pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my ork 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 t u to the best of my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU IN E CT I <br /> SIGNED TITLE <br /> DRAW PLOT' PLAN 7ON RE FRSE S IDE <br /> PHASE I . R DEP TMENT USE ONLY <br /> S <br /> APPLICATION ACCEP BY ld DATE k <br /> ADDITIONAL COMMENTS: <br /> PHASE , I OUT INSPECTIOX PHASE III/ NAL INSPECTIQN1 <br /> INSPECTION BY DATE VWINSPECTION BY DATE YM117 <br /> E H 1426 Rev. 1-74 .' <br /> 3/76 2M <br />