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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> 1601 � <br /> FOR OFFICE USE: ; <br /> E. Hazelton Ave' Stockton, Calif. <br /> Telephone : (2109) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ` <br /> n <br /> �• THIS PERMIT EXPIRES 11YEAR FROM DATE' ISSUED Date Issued 7 � <br /> (Complete In Triplicate) O2 02- _0 2 <br /> Application s hereby made to the San Joaquin Local Health District for a per to construct <br /> and/or install the work herein described. This l6plication 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 S �/ 10 <br /> .� CENSUS TRACT <br /> �/' <br /> Owner's Name i; Phone iL273 � r <br /> Address citr r <br /> Y X <br /> Contractor's Name <br /> License <br /> i <br /> TYPE OF WORK (Check) :. NEW WELL DEEPEN /% .RECONDITION /% DESTRUCTION /_7,/ <br /> PUMP INSTALLATION - PUMP REPAIR <br /> / / <br /> Other /_7 PUMP REPLACEMENT /? <br /> 61 k <br /> DISTANCE TO NEAREST: SEPTIC TANK - <br /> I. <br /> Q SEWER LINES Qd PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTHER ' S <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _—� Cable T.vol _-D. a.._,o Well_Excavation ,__ _ <br /> Domestic/private Drilled Dia, of Well Casing fr <br /> Domestic/public Driven h Gauge of Casing <br /> Irrigation Gravel Pack Depth I.of Grout Sealg—� 1 <br /> Cathodic Protection x Rotary <br /> Disposal Type of Grout <br /> Other ` ,. . Other Information { <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I� <br /> Type of Pump p H.P. <br /> PUMP REPLACEMENT: J- / State Work Doner .- <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter j 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}jaill furnish the San Joaquin Local Health District a <br /> TELL 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 />'RIOR TO GRO NG AND A NAI, INSACTION. d,� <br /> SIGNED TITLE f <br /> 2:77DRAW-PL6T PLAN 'ON REVEPSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?RASE I l <br /> APPLICATION ACCEPTED 'BY l DATE . <br /> ADDITIONAL COMMENTS:,; IF i <br /> PHASE II GROUT INSPEC N I SE /FI INSPECTI N ' <br /> CNSPECTION BY D E (INSPECTION DATE { <br /> E H 1426 Rev. 1--74 / , ' <br /> 3/76 2M <br />