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teat Ie o%,s#' C / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE40 FICE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,6- <br /> THIS <br /> ti-THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - X76 <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 appXication is made in compliance with San Joaquin" <br />, County Ordinance No. 1862 and the Rulesand Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / e -,.�• CENSUS, TRACT <br /> .Owner's Name p Phone <br /> 'Address �'ct.Y' cd -y City c�JFx' <br /> V <br /> Contractor's Na License # / 'Phone , <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN '/? RECONDITION /7 DESTRUCTION <br /> AL �f <br /> PUMP INSTALLATION —PUMP PUMP REPAIR /� PUMP REPLACEMENT /7 f <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; <br /> PROPERTY LINE - PRIVATE DOMESTLC WELL' PUBLIC DOMESTIC WELL i <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 V � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical yR Surface Seal Installed,-BY: <br /> Al <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. f �� <br /> V <br /> -PUMP REPLACEMENT: . / / State Work Done <br /> PUMP,..REPAIR: Al State Work Done <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth � <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r <br /> and the State of California pertaining to or regulating'weli ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well,, I will furnish the San Joaquin Local Health District a i <br /> WELL DRILLERS REPORT of the well anal notify them before putting. the..well in.use.... .The above <br /> 'information is true to the-best af- my.. f=ledge and belief. I WILL CALL FOR -A GROUT INSPECTION <br /> PRIOR TO UTING AND A F S 10 . <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN 0 ERSE SIDE <br /> FOR DEPARTMENT USE ONLY . i <br /> PHASE I a <br /> APPLICATION ACCEPTED BY ��, DATE a <br /> ADDITIONAL COMMENTS: - <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 'lD '� w <br /> E H 1426 _ Rev. 1-74 1.17 9M t <br />