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mow•2v��.£.�ten.-v+r� �_�� <br /> f <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOFFOFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone-( 2091 .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued - -77 <br /> k t (Complete In Triplicate) <br /> Application is Aereby 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 /> i County ordinance. No. 1862 and the Rules and Regulations of the S Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> � <br /> Owner s Phone Y •f Name Y_'7`./1�-�?..r.�.�L ' <br /> Address City . . <br /> Contractor s Na ✓ -_- i� C]° License #946AA4 Phone <br /> T ` `7 « S i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION / DESTRUCTION f J <br /> PUMP INSTALLATION �_PUMP REPAIR 1-1—pump REPLACEMENT /=7 <br /> Other Ll <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 /> f Industrial Cable Took. Dia. of Well Excavation � <br /> f Domestic/private Drilled Dia. 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: Contractor (-:; <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State WorkDone <br /> PUMP -REPAIR: /-7 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-Heal th•- istrict <br /> and the°State of California pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> f 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 GROUTING AND A FINAL INSPECTION. ° <br /> SIGNED i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' <br /> T F DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY6 q. <br /> F ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAn I/,KNA1,w INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1177 ,. -2K <br /> E H 1426 Rev. 1-74 <br />