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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: V/1601 E. Hazelton Ave. , -Stockton, Calif. F <br /> Telephone : (209) ,466'-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES, 1 YEAR FROM DATE ISSUED Date Issued ±-22--29" <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 /> A-14 : 2s5--15'V -z/ I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ Phoneltt a <br /> Address City <br /> Contractor's License �� <br /> r e. ® License # P1o.27b6 oPhone ,_, <br /> Contractor's Name �.----� <br /> E TYPE OF WORK (Check) : NEW WELL/7/ DEEPEN '/::; RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION.. / PUMP REPAIR/ / PUMP REPLACEMENT <br /> .:N <br /> Other /_/ . N <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 I <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven 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 /> PUMP INSTALLATION: Contractor --� <br /> Type of Pump H.P. <br /> I PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: �_/ � State Work Done.: . �- <br /> DES-TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Materiall;.and P; acedure a <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 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 GROUTI D A INAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PT;OT FLAN ON REVERSE SIDE) � <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY BATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIj`FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY, 2 DATE <br /> 3/7�'W <br /> E H 1426 - Rev. 1-74 _ <br />