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- r•« SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 1466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7� <br /> (Complete In Triplicate) <br /> Application is hereby.msde 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 4,14 �lz- ,+/ a� �'1 CENSUS TRACT { <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License 41 ! 7.3 Phone ( -S-f3 <br /> TYPE OF WORK (Check) : NEW WELL /-7 "DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PPMP REPLACEMENT <br /> Other .�� <br /> DISTANCE TO-NE-ARES,T..;—SEP.TIC_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_ sa 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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / . / State Work Done <br /> PUMP .REPAIR: A /,./ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter . Approximate Depth <br /> l 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 i <br /> after completion of my work on a new 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 the-best of- my.knowledge and belief. I WILL, CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROWZINGMD A FIW INSPECTION. { <br /> SIGNED I TITLE <br /> RL1W £'h T PLAN `ON RE FRSE SIDE I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION, PHASE I14/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H~.11+26 Rev. 1-74 . <br /> 3/76 2K <br />