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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. <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued----S-' V-72(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 Ile -GLIGiq CENSUS TRACT <br /> Owner's Name Phone <br /> } <br /> Address City r <br /> Contractor's Name / //L� License �F %hone C�- 102— . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / I RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 1 I <br /> i <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 J� <br /> E Industrial Cable Tool Dia. of Well Excavation /.2 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> DC�C Irrigation Gravel Pack Depth of Grout Seal <br /> CathodicProtection.k Rotary Type of Grout -{�--- _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:41 <br /> PUMP INSTALLATION: Contractor <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 the best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G AND A FI INSPECTION. <br /> SIGNED / TITLE <br /> DRAW- PL T PLAN 'ON RE FRSE 'SIDE) <br /> FOR DEPARTMENT :USE ONLY <br /> PHASE I <br /> i <br /> APPLICATION ACCEPTED BY ,p �/ [.�' __ DATE LSF -24 '?�-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ' PHAS /ANAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY - - laP4. . DATE � — <br /> R H 1426 Rev. 1-74 <br />