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SAN JOAQUIN LOCAL HEALTH- DISTRICT s� <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. ],6-J/3d 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IL-Ly-2 <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 /> JOB ADDRESS/LOCATION ° CENSUS TRACT <br /> : Owner's Name ., phone <br /> Address 4/07 City �r <br /> fContractor's NameC7 e mar-, <br /> License #ea�� Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/_%,. RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION/ / 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 /> PROPERTY'LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial . . N- Cable Tool Dia. of Well Excavation <br /> Domestic/private' s Drilled Dia. of Well Casing <br /> Domestic/publicDriven` 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 BY: <br /> R PUMP INSTALLATION: Contractor <br /> —,-rc;. p rA r, dLL-- <br /> TYPe. of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done 42 G° <br /> 1 PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 do a new well, I will furnish the San Joaquin Local Health District a <br /> f 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 GROUT `INSPECTION <br /> . PRIOR TO GRO NG AND A F TNS PE ION. <br /> SIGNED TITLE - <br /> DRAW,PL T PLAN ON_RE EkS.E SIDE <br /> - FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY o DATE 1-2-d:& <br /> E .H 1426 Rev. I-74 3/76 2M <br />