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►v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7zl-,SrK5)4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4zd z-Z4" <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 ADDRESSES /�f� �jl` �"/ CENSUS TRACT <br /> Owner's Name - / I !�I .y s , r Phone <br /> Address City <br /> Contractor's Name /!6 License i17ae�6e,4 Phone��/� t0 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT / T <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES/ ff PIT PRIVY <br /> SEWAGE DISPOSAL FIELD --- CESSPOOL/SEEPAGE PIT /,do_f-OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELI/22d—+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 2)7 <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 OV <br /> Type of PumpH.P. �. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> =S®RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> $fter 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 GROUTING AND A FINAL INSPECTI L <br /> SIGNED TITLE <br /> PLOT-PIM ON REVERSE SIDE <br /> FOR DEPART MEN T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASX II ROUT INSPECTION PHAS PECTION <br /> DATEINSPECTION INSPECTION TE <br /> E H 1426 Rev. 1-74 1-74 2M <br />