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SAN JOAQUIN LOCAL HEALTH DISTRICT � .'• <br /> FOBi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. J�� <br /> J THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued T J 7-s <br /> (Complete In Triplicate) ""`"" <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct Y� <br /> and/or install the work herein described. This application is made in compliance with San Joaqu <br /> County Ordinance No. 1862 and the. Rules and Regulations of the San J uin Local Health District <br /> ! JOB ADDRESS/LOCATION CENSUS TRACT <br /> I Owner's Name - Phone <br /> Address' 1_64 <br /> City G� <br /> ! Contractor's Name6A& 5Ea&zx License # Phone <br /> r <br /> TYPE OF WORK (Check); NEW WELL "/-7 DEEPEN 1-7 RECONDITION / DESTRUCTION _� <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—pump REPLACEMENT <br /> other / / <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY �, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTR .: <br /> . PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI0N5 � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domastic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> "— Gauge of Casing \ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> j _ Cathodic Protection Rotary Y Type of Grout <br /> Disposal . - Other Other Information <br /> Geophysical. ".---� ------ <br /> -ur€ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pujl�d_u <br /> H.P. � <br /> Pte' MEPI'ANT State Work Done <br /> PUMP '.REPAIR.: -7 State Work Done _ <br /> ES:TRUCTION.' OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local health Di <br /> and the State of California pertaining to or regulating well construction. strict <br /> AYS <br /> after completion of my work on a new well, I will furnish the San Joaquin LocalHealthDistrict 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 of my.knowledge and belief. I WILL CALL-MR A 'G <br /> PRIOR TO GROUTING A FIN �INIS�FEI�ON,, ROUT INSPECTION <br /> TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> ! PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION °ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE6: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> � � " _E H 1426 Rev. 1-74 <br />