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y <br /> _ Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF:;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. P <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedJAN 9 - 1978 <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 Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION <br /> . , CENSUS TRACT . <br /> Owner's Name <br /> Phone R3 <br /> Address S� f ,2 City <br /> Contractor's Name License �!1rhon� <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN '/_7 RECONDITION ff DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP PAIR -/_7 PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANIt 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 Well Excavation <br /> TA <br /> 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 'B <br /> PUMP INSTALLATIONa Contractor <br /> Type of, Pump H.P. <br /> PUMP REPLACEMENT: .. / / State Work Done <br /> PUMP '.REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with a 1 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 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 G <br />'RIOR TO -ROUTING AND FINAL INSPECTION. The <br /> INSPECTION <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br />'RASE I FOR DEPARTMENT USE ONLY <br /> CPPLiCATION ACCEPTED BY DATE -�7� <br /> LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA.SEgAIILT INSPECTION <br /> CNSPECTION BY _ DATE INSPECTION BY DATE - ice <br /> E H 1426 Rev. 1-74 <br />