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SAN JOAQUIN LOCAL HEALTH DISTRICT ~ <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2d2-/,9 <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 Rut . d Regulations of the San Joaquin Local Health District. <br /> a � <br /> JOB ADDRESS/LOC N CENSUS TRA++C��T . <br /> Owner's Name Phoneg4r�` <br /> Address <br /> Cit <br /> Contractor's Name _'License,00 3 Phone 4 6 <br /> TYPE OF WORK (Check) . NEW WELL/ J DEEPEN / / RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR /%� PUMP REPLACEMENT /7 <br /> Other / J <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/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 i <br /> PUMP .REPAIR: /r State Work D �I 1 <br /> DESTRUCTION OF WELL; Well Diameter Approxi a 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PL76T PLAN ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _16F 2'2, ZI <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE/III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ' C�o 3/76 2M <br />