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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -70-F,-"OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 6 4I6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> J6_µSS IQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (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 /> + CENSUS TRACT <br /> JOB ADDRESS/LOCAT N cx� �� i(� � �/�/ r -- ---�-- <br /> � _ Phone <br /> Owner s Name <br /> j Address City <br /> _&Celt� <br /> Contractor's Name License �����/ Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> ` PUMP INSTALLATION M�' REPAIR / / PUMP REPLACEMENT /7 <br /> �- Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAr FIELD CESSPOOZ/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS 6 <br /> In ustrial L.,otable Tool Dia. of Well Excavation <br /> mestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing de _Ns <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 ka4W,12 0,5,4,4� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> i DESApproximate DESTRUCTION OF WELL: Well Diameter PP 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> information is true to the est of- my.knowledge and belief. I WILL COL FOR A GROUT INSPECTION. <br /> PRIOR TO 0 I D A INSPECTION. <br /> SIGNED a TITLE <br /> DRAW PZ T PLAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATEif INSPECTION BY DATE /�: / <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />