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IESAN JOAQUIN LOCAL•.HEALTH DISTRICT <br /> FOE OFFICE USE: 1601. E. Hazelton .Ave. , Stockton, Calif. � <br /> Telephone: '(209) 466-6781 } <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No'.��// - I <br /> yl <br /> THIS PERMIT. EXPIRES .l YEAR FROM DATE ISSUED . Date Issued ` '��� <br /> j '(Complete- In Triplicate) <br /> Application is hereby made t. the San Joaquin Local Health District for a.permit to construct <br /> and/or install the work, herAn described This application is made in compliance with San Joaquin; <br /> County Ordinance No., 1862 aria the .Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , a�., <br /> r CENSUS TRACT <br /> Owner's Name I Phone � <br /> rp... <br /> city' Esc i <br /> Address F <br /> Contractor' s Name <br /> +, License # o?7990/p Phone j 7 <br /> TYPE�OF�WORIQ Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /7 _ <br /> ., -•PUMP 'IINSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> ' Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> KPROPERTY LINE -`PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <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 <br /> Irrigation: � Gravel Pack Depth of Grout Seal a <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other` Other Information <br /> Geophysical j Surface Seal Installed By: <br /> r - _ <br /> PUMP INSTALLATION: Contractor <br /> Typel of PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> . <br /> t, a. z. <br /> -_--•--:�.;i��.. _.-,..�.,r-rte..--,.��._: ,� <br /> r PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well` Diameter Approximate Depth <br /> Descibe 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 reguldt'n.g well�'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I wills 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 /> k - <br /> information is true to the I'�best of• my knowledge and belief.` I WILL CALL FOR A GROUT INSPECTION. - <br /> PRIOR <br /> NSPECTION -PRIOR TO GROUT4G ANDA N4 INSPECTION. <br /> SIGNED ; TITLE <br /> OF (DRAW PLOT PLAN ON REVERSE SIDE <br /> I� ./,FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY t c - DATE (� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FIN INSPECT ON <br /> INSPECTION BY Ill DATE INSPECTION B DATE <br /> 6/77 _2N- - - <br /> E H 1426 -Rev. 1_74 .. - - <br />