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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ,,*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26- _51° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _/5-76 <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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name A, Sid Phone , ' ., 3 .� <br /> i <br /> Address -e__ City : .Se.A°Yt­� <br /> Contractor's Name License #27�-O/ 9 Phone '$R-�.-&)7 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /7 <br /> Other 1_7 <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 °Q <br /> Domestic/private Drilled Iiia. of Well 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 . . <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: 4Conrractor k 111 <br /> -Type of Pump 4 <br /> H.P. - <br /> PUMP <br /> .P.PUMP REPLACEMENT: / / State Work Done . <br /> PUMP .REPAIR: State Work. Done - Aas 2_ <br /> DESiTRUCTION 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 /> WELT-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 OU ING D A FINAL INSPECTION. <br /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE DTETd <br /> PHASE I +} £• i.� FOR DEPARTMENT USE ONLY <br /> �� <br /> APPLICATION ACCEP_.TED.-BY • ,_ DATE ' C �.! 7� <br /> ADDITIONAL COMMENTS:' <br /> PHASE I. GROUT INSPECTION PHASE III NaINSPECTIO <br /> INSPECTION BYDATE '.''' ' INSPECTION BY DATE / <br /> : I .� <br />