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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z __ ;F5- <br /> SII <br /> THIS PERMIT EXPIRES 1 YEAR- FROM DATE ISSUED Date Issued <br /> u (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 worl herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and th 'I Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION M. CENSUS TRACT <br /> Owner's Name v Phone - <br /> Address o till a ,i -,o City <br /> Contractor's Name �cr, a� a/ ` �- �� License # 2n Phone <br /> TYPE OF WORK (Check) : NEW WELL J // DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> t = PUMP INSTALLATION / PUMP REPAIR I I PUMP REPLACEMENT f7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ��L PIT PRIVY - <br /> SEWAGE DISP AL FIELDr C SSPOOL/SEEPAGE PIT ----- OTHER ` n <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '!— PUBLIC DOMESTIC WELL V 1 <br /> INTENDED USE' TYPEiIJOF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial II Cable Tool Dia. of Well Excavation <br /> Domestic/private °I1 Drilled Dia. of Well Casing <br /> Domestic/public ][ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal- �� <br /> Cathodic Protection ; illi Rotary Type of Grout zy=Q 451,11 <br /> Disposal :I1 Other Other Information {� <br /> Geophysical Surface Seal Installed By.: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I'/ / State Work Done <br /> PUMP-':REPAIR: ,•/m-/=S-ta-t4--Work=Done . <br /> DESTRUCTION OFWELL: 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 myj�work on ainew 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'lithe .best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND FINAL,INSPECTION. <br /> E SIGNED '' li TITLE �-c�� <br /> DRA L O T' PLAN 'ON RE FRSE SIDE) <br /> FOR EPART NT USE ONLY <br /> PHASE I � � , <br /> APPLICATION ACCEPTED BY �iJov- DATE 1130 Z-7. <br /> ADDITIONAL COMMENTS: <br /> PHASE II UPUT INSPEC ON PHASE III/FINAL INSPECTI N <br /> INSPECTION BY - DATED INSPECTION BY DATE 41 J>V21 <br /> „ 3/76 2M <br /> E H 1426 Rev. 1-714 �I' _ <br />