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J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE'USE: /1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Teiephoiie i `(209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �1/gam <br /> 1c' <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 J-oaquklh <br /> F County Ordinance No. 1862 and `the Rules and Re ulatious of the Sark Joaquin Local Health.District,' <br /> JOB l.S�'7G ADDRESS LOCATION _ G "L CENSUS TRACT ' <br /> � <br /> il �J <br /> Owner's Name 4 � Phare <br /> Address _ ., a dzCity <br /> Contractor's Name � � e--i _ License Phone 4`����.Ii <br /> TYPE OF WORK (Check) : NEW WELL'/ DEEPEN /? RECONDITION / �DE5TRUCTIONf <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP, REPLACEMENT <br /> _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ <br /> PROPERTY, LINE - PRIVATE DOMESTIC WELL' BL <br /> _ PUIC DOM <br /> BSTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> Domestic/private Drilled Dia. of Weil Casing <br /> Domestit/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> } , <br /> Geophysical Surface Seal Installed By: <br /> V <br /> C:& <br /> R <br /> '\=PUNP INSTALLATION: Contractor al <br /> Type of Pump H.P. , <br /> d <br /> PUMP REPLACEMENT: . State Work Donx-- -' <br /> PUMP .REPAIR: /7 State Work Done 'T ` <br /> # AES TRUCT_ION.OF WELL: Well Diameter Approximate Depth ` <br /> Describe Material and Procedure <br /> Y ;hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State bf California, pertaining to or regulating well"construction. Within Flftk T Chits <br /> after completioa-of my work3on `a"new`well, 'I'will furnish the Sari Joaquin'Zocal-Health;, District a <br /> WELL DRILLERS-REPORT=o€rthe--well .and,notif.y:.-them_before_putting_the .well.,.in.Muse,.—The,a#�iove' <br /> t information is�.true to the-best of my knowledge and belief. I WILL 3CALLJOR A GROUT &SPECTIOk... <br /> PRIOR TOG UTING• FINAL INSPECTION. <br /> SIGNED TITLE -' <br /> D W PLAN 'ON OMI SIDE N� <br /> l <br /> jo FOR DEPARTNENT USE ONLY .a° <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /`;' <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT ImSPECTIPHASE III FINAL INSPECTION' <br /> ON <br /> INSPECTION BY DATE INSPECTION BY �ATE <br /> �. E H 1426 Rev. 1-74 � x!76 214_J <br />