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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif.l <br /> ! <br /> Telephone: (209) 466-6781 # <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4k_1 S-s� <br /> THIS PERMIT EXPIRES 1TEAR 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. 62 and the Rules and Regulation of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI <br /> CENSUS TRACT i <br /> Owner's Name Phonee-,-11_77 9� <br /> Address � <br /> Cit � <br /> Contractor's Name ' <br /> License �` 7,3 Phoned ���r <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /? DESTRUCTION /_7 <br /> / <br /> PUMP INSTALLATION / PUMP REPAIR /7 PUMP REPLACEMENT /^f <br /> Other /_7 --•- <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER L�NES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /�'a--CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIQVS <br /> Industrial Cable Tool Ria. of Well .Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ - Domestic/public Driven Gauge of Casing /p <br /> Irrigation Gravel. Pack �. Depth of Grout Seal <br /> Cathodic Pr'otection Rotary Type of Grout <br /> -Disposal ' ("507 <br /> „ ��� <br /> p ..- Other Other Ym€ormatian _ <br /> Geophysics] Surface, Seal Installed BY: 1 <br /> PUMP INSTALLATION: Contractor ! <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: j/ / State Work Done <br />... 'UMP:REPAIR:.- /"��State ,lorki3vrr <br /> ES1RUCTION OF WELL: Well Diameterf <br /> Describe Material and Procedure Approximate Depth ; <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 9 <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 true to the-best-of my knowledge and belief-. I WILL CALL FOR A ,GROUT INSPECTION , <br /> PRIOR I0 ROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> F PARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY j _,�9!A� <br /> � RATE � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 7 DATE INSPECTION BY DATE - <br /> /J -�cl <br /> E H 1426 Rev. 1-74 <br /> 1-76 7M <br />