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SAN JOAQUIN LOCAL HEALTH DISTRICT '1, <br /> -F-OF-OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton-, Calif. <br /> Telephone: (209)' '466-6781 :. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No. Z -/p_5- �o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - ..S 7 <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 Rule and Regulation of the San Joaquin Local Health District. <br /> ai1-11 <br /> JOB ADDRESS/LO ION :��� CENSUS TRACT <br /> Owner's Name Phone 0-�� <br /> I <br /> Address City <br /> ,i <br /> Contractor'sName .4License #/O'>�hone.2 �����'� <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITI -r /-7 DESTRUCTION <br /> AL <br /> PUMP INSTALLATION -PUMP PUMP REPAIR / PUMP REPLACEMENT /_T <br /> Other <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. t <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i - <br /> PUMP INSTALLATION: Contractor A <br /> Type of Pump H.P. t <br /> PUMP REPLACEMENT:' /_�, / State Work Done, <br /> IIII <br /> PUMP REPAIR'.- /fir State Work D ;e�- - r.- + - <br /> DES•TRUCTIONi OF WELL: Well Diameter Approx ate pth <br /> Describe Material and Procedure <br /> I hereby agree to comply, with all laws and regulations of the San Joaquin Local Heal..th .bistrict <br /> -T <br /> and the State of California pertaining to or regulating we11 ''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 af " he 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 it TITLE <br /> I� (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> O FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY j : <br /> DATE <br /> ADDITIONAL COMMENTS: 3 <br /> PHASE II GROU SPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION .BY 6 DATE INSPECTION BY DATE 7 7 <br /> 777 <br /> E H 1426 Rev. 1-74[ <br />