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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$MFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR.PUMP PERMIT Permit No. � <br /> F _71 - <br /> THIS 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 Regulations of the San. Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATI <br /> Owner P s Name µ ? c -�Y� a.rte- Phone " �9 6 /j— <br /> � Address city� <br /> Contractor's Name License. �#�ql��/3 Phone �-Z/Z / <br /> TYPE OF WORK (Check): NEW WELL/PT' DEEPEN /7 RECONDITION /7 DESTRUCTION r7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br /> Other <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 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 oa <br /> Cathodic Protection __ L_ --Rotary Type of Grout G <br /> Disposal Other Other Information _ <br /> Geophysical <br /> .. . . - Surface Seal Installed By: <br /> ` PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. ;zr_� <br /> d _ d <br /> PUMP REPLACEMENT: / / State Work Done <br /> Work Hone <br /> - PUMP-:REPAIR:- �-� . --/7- ---State <br /> _ <br /> nTRUCTION OF WELL: Well Diameter Approximate 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 a <br /> i 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 FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND A AL IN PECTION. <br /> SIGNED TITLE <br /> PLOT LAN ON REVERSE SID r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4 DATE '2 57 96 <br /> ADDITIONAL COMME*TS: <br /> PMAS&ITWGROUT INSPECTION PHA E I FINAL INSPECTION <br /> INSPECTION BY DATE =--?,--745 INSPECTION BY ` DATE - I <br /> ' 'i E H 1426 Rev. 1-74 1-74 2M <br />