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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OF ICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-3 4d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssueyAR 151978 <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 word herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local-Health District. <br /> JOB ADDRESS/LOCATION � �/' � .r'�- >�� �pe CENSUS TRACT <br /> Owner's Name �-� �1 Phone <br /> Address KGs city (d <br /> Contractor's Name Licenseoyl/AW Phonejz--? <br /> TYPE OF WORK (Check) : NEW WELL -/�EEPEN /�/ RECONDITION_/ /_ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK - -SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER -0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 20 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Csble Tool Dia. of Well Excavation .' C� <br /> Domestic/private Drilled Dia. of Well Casing _��3/ _ _. G <br /> Domestic/public Driven Gauge of Casing _fj <br /> ��:. �Igation 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 /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 'cons.truction. 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 sell 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 />?RIOR TO GRO IN D A FINAL INSPECTIO <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> f <br /> APPLICATION ACCEPTED BY DATE J 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IT /FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION $Y !; " DATE r. <br /> E <br /> H. 1426 Rev. - 1-7477 _ 2M ` <br />