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!/ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE; C& 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 <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 �. �JJ �o.� L ��a CENSUS TRACT <br /> Owner's Name ..T 6A.1 Phone 9 Co-,53GZ <br /> Address City Fla 0C M 0`1V6 p v <br /> Contractor's Name Its'/. LAS 0.-1 _ _ License-#p�7��/0 Phone <br /> . i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION / / DESTRUCTION /_ <br /> i PUMP INSTALLATION / / PUMP REPAIR/5;� PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: ^ SEPTIC-TANK SEWER LINES PTT 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 x Cable Tool Dia., of Well Excavation I <br /> Domestic/private. Drilled Dia. of Well Casing. l � <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 /> i Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done pb ejci.P �•- _ _ <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 /> 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 <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 i! <br /> PRIOR TO G UTING AN A INAL INSPECTION. <br /> SIGNED TITLE <br /> MAIW.sPOT' PLAN 'ON REVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDLBY DATE ' <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSP CTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY44,Z" DATE / <br /> �-o <br /> - <br /> E H 1426 Rev. 1- 74 3/76 2M <br />