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r tµ 3 <br /> SAN JOAQUIN LOCAL •HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per No.� <br /> THISPERMITEXPIRES 1 YEAR FROM DATE ISSUED , Date Issued /,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 �ul s and Regulations of the San Joaquin Local Health.-District. <br /> JOB ADDRESS/LOCATION e <br /> 7 z, c.9 . f ,i CENSUS TRACT <br /> Owner's Name -e _ Phone <br /> Address of a <br /> City cif <br /> Contractor's Name fLicense IE�?�] Phone 1 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / c,L PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> /d? j SEWER LINESfly w. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '% ,CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE j-V PRIVATE DOMES'TI,C 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 /> 1 <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation "Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary r,Type'. of Grout 2. J_ <br /> Disposal Other Other Information <br /> Geophysical �. X Surface Seal Installed By: _._... f <br /> P NT INSTALLATION: Contractor <br /> - I�t 2 ' �, t,r+� f 1�-- av <br /> Type of Pump - - ..,,k, H.P. f <br /> PUMP /REPLACEMENT: / / State Work Done <br /> PUMP,`REPAIR: <br /> / / State Work Done � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 41 <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 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 .knowled.ge and belief. _I.._WILL CAL _FO.R-A_GROUT....IN.SPECTION <br /> PRIOR'TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT .USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY j/ DATE <br /> ADDITIONAL COMMENTS: ^" T <br /> PHASE II GROUT INSPECTION PHA INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE _7-�� J <br /> s- i <br /> �..- X177 _ 2M <br /> E H 1426 Rev. 11-74 � <br />