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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Permit No. 11-6 <br /> 0 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b0i] <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 /5�.�/� /✓G�J7 CENSUS TRACT <br /> Owner's Name Phone 7•z� ��6 <br /> Address /�� GIST city <br /> Contractor s Name <br /> � License #x/ Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL-fi/ DEEPEN RECONDITION-T7 DESTkUtTIOW/T^+ - <br /> PUMP INSTALLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other L77 <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES PIT PRIVY <br /> K ^� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial DC Cable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing A2 eplqI <br /> NX 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. L /� <br /> e%A <br /> PUMP INSTALLATION: Contractor O <br /> H.P. <br /> Type of Pump <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 al .--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 GRO D A FINAL TION. <br /> SIGNED TITLE <br /> (D W P' T PLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I :'DATE Z <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE .III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -3-0 `T <br /> ` 3/76 .2M <br /> E H 1426 Rev. 1-74 <br />