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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F(IR 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 d0113 <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 9! ,!<: S. ��% �C � CENSUS TRACT <br /> Owner's Name �C � - Phone gV� <br /> Address LG City %l ^J-.. --- <br /> Contractor's Name �.r r� d �C� License Phone - � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP INSTALLATION X7 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> 0 Cher Qv 7" O L--i <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 /> -- eg <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 5 <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 S H.]V—. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> OLP A46LL CP�azof <br /> DESTRUCTION OF WELL: Well Diameter S Approxima e Depth <br /> Describe Material and rocedure d'Gr <br /> S- <br /> I hereby agree to comply with all Laws and regulations of the Sall 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 FOIXA GROUT INSPECTION <br /> PRIOR TO G ING AND A aNkL .INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, I /FINAI, INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - _ <br /> 6/77 _ 2M <br /> E H 1426 Rev. . 1-74 <br />