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al" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6--1!2Z" <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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION did.P CENSUS TRACT <br /> Owner's Name Phone l fo 0-y .� <br /> I <br /> Address City _ <br /> Contractor's Name LJ.Cj License #�� _l17.3 Phone.:j� <br /> - <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /?_ DESTRUCTION /-7f <br /> PUMP .INSTALLATION PUMP REPAIR'/ 7 PUMP REPLACEMENT7'/- <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 z Gauge. of -Casing_ ,:�t <br /> `- - Irrigation` "- . Grivel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout .' <br /> Disposal Other Other Informat'ion'' <br /> Geophysical ' Surface Seai" Installed 'B <br /> 'PUMP INSTALLATION: Contractor # <br /> Type ;of Pump H.P. <br /> PUMP REPLACEMENT: . / State Work DoneB `°- t <br /> State Work Done y <br /> PUMP .REPAIR: i <br /> DESTRUCTION OF WELL Well '-Diameter Approximate Depth <br /> Describe Material and Procedure I <br /> I hereby agree to comply.-wi;th.a11•..3-aws-and regulations of- the San-:Joaquin Local Health District <br /> and the State of California-pertaining to or regulating well `cdnstruction. Within FIFTEEN DAYS <br /> after completion of my work :on a new well, Ifwill furnish*the San .Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notifyithem before puttini the..well. in.use... .The above, <br /> information is true to- the-best-of- my-knowledge and belief. I GILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND INAL INSPECTION: <br /> SIGNED L TITLE <br /> c <br /> (DRAW PLOT PLAN ON REVERSE 'SIDE) <br /> 'OR <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP Y Q/�L�/�/. DATE ,3 ` - 7(� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT :INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE .?G <br /> E H 1426 Rev. 1-74 r` h/75 2M <br />