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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />-TO-FI-"OFFICE USE: 1601 E. Haze`- ton .Ave. , Stockton, Calif. R <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '2;2_A,?6-j <br /> Ii'ITHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Regulatio s of the San Joaquin .Local Health .District. I <br /> e yg p d-, 9 f <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> h � <br /> Owner's Name Phone <br /> t <br /> Address <br /> Contractor's NameI� t License # Phone <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN/ / iRECONDITION '/ / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Ot 4er / f a <br /> I <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 W611,' Excavation­__ <br /> Domestic/private �. Drilled.. Dia:s-of Well Casing <br /> Domestic/public. y.- --,Driver' ` Gauge of Casing <br /> - Ir `gation Gravel Pack Depth of Grout Seal N <br /> Cathodic- Protection Rotary Type of Grout a <br /> D}isposal , Other Other Information i <br /> Geophysical Surface Seal Installed By: <br /> 1, <br /> PUMP INSTALLATION: Contractor i <br /> TYPe of Pump H.P. _ �`�_ `II <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �a <br /> v Describe Material and Procedure X <br /> Ii 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: tnTithih 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 -the Well. in use. The ,above <br />,information is rue o the best of my knowledge and belief;-.!'WILI CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR NG I� L SPECT ION. - <br /> SIGNED-i.=" _ �--TITLE <br /> iM (DRAW PLOT PLAN ON REVERSE SIDET <br /> ��° FOR DEPARTMENT USE ONLY <br />'PHASE I �� <br /> APPLICATION ACCEPTED BY �• DATE 3'II-77 <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT 'INSPECTION PHAS II FINAL INSP CTI )N <br /> INSPECTION BY DATE INSPECTIONvBY DATE J <br /> ... <br /> 1177 , 2M <br /> E H 1426 Rev. -701" <br /> _ - <br />