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r _ <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 Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION U1, �, ;,> '-J, �_ _ CENSUS TRACT <br /> z <br /> Owner's Name Cr Phone�(a <br /> eL <br /> Address 1 � 7 �j. 1� City <br /> Contractor's Name License 91k 1-323 Phone 34 <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 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 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic \ <br /> /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 /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: f� 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 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 FIN INSPECTIO . �I � <br /> SIGNED TITLE <br /> RAW- T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEezt <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ii /FINAL INSPECTION ! <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br /> • ���� <br />