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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk70FFICE USE: 1,601 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 v7^7 -71 <br /> (Complete In Triplicate) <br />' Application is Aereby 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 ipaquin <br /> Count}ii'Ordinance No. 1862 and the Ru Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC ION =§ &To CENSUS TRACT <br /> r Phone <br /> Owners Na <br />' Address Ci <br /> k Contractors Name <br /> License 01 >73ftone <br /> TYPE 0iF WORK (Check): NEW WELL /_7 DEEPEN /_ RECONDITION �_ <br /> _ - ITION � DESTRUCTION /7 , <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT I 'T r <br /> _ Uf Other �,;.. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT OTHER (S. <br /> PROPERTY LINE -- PRIVATE OMESTIC 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 B <br /> PUMP INSTALLATION; Contractor <br /> I� Type of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP .REPAIR: State Work Don <br /> a <br /> DESTRUCTION OF WELL: Well Diameter ApproximaW Depth ' w <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and 'xegulations, of''the `San,,Joaquin Local, Health Fintrift . <br /> F 'and' the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completionof my 'work on a new well, I will furnish the San Joaquin Local Health District' e <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 X10 GROUTINGj AND, A`- FINAL INSPECTION. <br /> SIGNED: , <br /> TITLE <br /> � ` �.�. _ _.-�,--�------*---T. <br /> :. (DRAW PLOT PLAN ON REVERSE SIDE) _ { <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASEII <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:a '' <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY W\ F'1 „ __ DATE INSPECTION DY DATE <br /> T Fla <br /> E H 1426 Rev. 1-74 6� __ <br />