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by <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT ' <br /> 4, FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;Z2- 0� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g7- <br /> (Complete <br /> 7/(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/LOCA ION � r� cQ c---- CENSUS TRACT <br /> Owner's Name Phone .�� <br /> f Address . // 9 7-5� _ V /�-r/l _.._..._.,_.—_ City J <br /> Contractor's Name /� License #2-373 PhoneW-.1 -3S- - <br /> - i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -,-,, ­PUMP REPLACEMENT /? ; <br /> Other <br /> DISTANCE TO-NEATREST-:6--S-EPTIC-'TANK- -—„SEWER-LINES- ' `PIT PRIVY <br /> it <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> —) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �- Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private y Drilled Dia. of Weil Casing y <br /> v <br /> Domestic/public _ _ _Driven M 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 /> i � E <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. H.P. Lto <br /> PUMP REPLACEMENT: / �'/ _ State Work Done <br /> PUMP .REPAIR: /'State Work Done,. ill <br /> F I <br /> DESTRUCTION OF WELL: Well Diameter / r Appxoximate 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 furnish4.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 the best of knowledge and belief. I''WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GYMTIAN]jA INAL INSPRtTION. , " e <br /> SIGNED. <br /> W`PL T PLAN"ON REVERSE SInE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY 3 DATE �� 1 <br /> i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f HASE IV/FIYAJLOeINSPECTION <br /> INSPECTION BY DATE INSPECTION VS2PATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br /> i <br />