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F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r � <br /> FOEr ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. U"4�1 <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 /a-6`71 <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 5 I �-�► `e A-V-5— CENSUS TRACT <br /> Owner's Name Phone r Z 3 <br /> Address �{ �] City RUU� R <br /> Contractor's Name��� �� -- License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL AL/ / DEEPEN /_/ RECONDITION /_/� DESTRUCTION /� — <br /> PUMP INSTLATION x(I PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /-7 <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-0F-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia, of Well Excavation _ (A <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 B <br /> PUMP INSTALLATION: Contractor U N � - <br /> Type of Pump 5--bijPWA H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 /> 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 G UTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PLjASWyI/F1NA1INSPECTION <br /> INSPECTION BY DATE _ V INSPECTION B DAT4E 67 <br /> 7 7 _ 2M <br /> E H 1426 Rev. . 1--74 _- _ <br />