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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 =j '71 <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 /> J0$ ADDRESS/LOCATIONa - CENSUS TRACT r <br /> Owner's Name /'_ „ ,(� Phone ���2f-- <br /> IV <br /> Address 4a z City <br /> Contractor's Name License -xiv Phone-3 <br /> TYPE OF WORK (Check) : NEW'WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publics Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ' Other Information <br /> Geophysical £ Surface Seal Installed By: -_ <br /> PUMP . Contractor <br /> �) <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work .-Done ti <br /> I f <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 al '"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 thewell 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 GROUTING AND 'AjjqN4 TNS CTION. <br /> SIGNED i TITLE <br /> ' I/v4_(DRAW--PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY d DATE f- , <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 <br /> _ b/77 2M <br /> _ <br />