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k <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE ,OFFICE USE: r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D of tir <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1�- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> andJor 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 D CENSUS TRACT <br /> Phone _ —�a <br /> Owner's Name 0� <br /> , S <br /> Address city <br /> License # 6 Phone <br /> Contractor's Nacre IF�r, � 2��a���`,�,.��.��-- f�� <br /> i <br /> k <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION / / DESTRUCTION /- i <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT I� <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 /> rivate Drilled a. of Well Casing <br /> Domestic/private Di � <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 LAZvt� v� �` <br /> H.P. <br /> Type of Pump . <br /> PUMP REPLACEMENT: /hJ State Work Done�j�/ <br /> PUMP .REPAIR: / / Statek Work Done <br /> DESTRUCTION OF WELL: Well ,Diameter Approximate Depth <br /> D e s c"?b�e 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 /> i after completion of my workon a new well, I will furnish the San Joaquin Local Health District a <br /> f 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 GROUTINGAND A FINAL INSPECTION. <br /> SIGNED �+-a-�-zr TITLE <br /> DRAW FE61"I I"LAN' ON REVERSE SID <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ` DATE Z _ <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 A DATE <br /> } <br /> 3/76 2. <br /> E H 1426 Rev. 1-74 <br />