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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOB OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _;7,4- 9d 7JQ <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -?6 <br /> �, (Complete In .Triplicate) <br /> Application .is hereby madesto' 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 /> ,�e.,O - __'I rA l-e - ®?�- O 7 <br /> JOB ADDRESS/LOCATION _fj CF &gkCENSUS TRACT <br /> Owner's Name Phone <br /> Address . / <br /> � �r - v � City <br /> 5 <br /> Contractor's Name License # [&-7 Phone � `7 <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN/_% RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP. REPAIR / / PUMP REPLACEMENT / <br /> Other /77 <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 N�1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS b . <br /> Industrial Cable Tool Dia, of Well Excavation <br /> X Domestic/private Drilled 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 /> Pod <br /> PUMP INSTALLATION: Contractor p,�� <br /> of Pump S H.P. <br /> State Work DonePUMP REPLACEMENT: ' ` <br /> �61rrr1/� <br /> _ 4 <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 /> pertaining the State- of California pertaning to or regulating wel 1 '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 beforeiputting the .well in use. The above <br /> information is true to the-best of- m'Ykn ed a an belief. "I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO U ING AN A FIN P CTI N. � <br /> SIGNED ITLE � ` <br /> LAN 'ON FRSE SIDE ,; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I_ k <br /> APPLICATION ACCEPTED BY. <br /> ADDITIONAL COMMENTS: -' -DATE !F-/�,g .— I <br /> PHASE II GROUT INSPECTION P E II/ INAL INSPECTION/' <br /> INSPECTION BY DATE INSPECTION- By DATE c1 <br /> E H 1426 Rev. .1-74 376 2M <br />