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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£r�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -.S;z 1-d <br /> !'0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' g,'&j <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 Ordin nce No. 1862 a the Rules and Regulations of the San Joaqu Loc 1 Health District. <br /> r© x'137 ), I & Z <br /> JOB AilS.S/LOCATIONA t✓ < S TRACT <br /> Owner's Name W' Phone <br /> Address X0 L'� City <br /> License <br /> Contractor's Name f' Phone <br /> 1s <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INST LATION PUMP REPAIR'/-7 PUMP REPLACEMENT <br /> Other i <br /> ,_ y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP AL FIELD ' 6$"P"L-/SEEPAGE PIT- OTHER \ <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLICIESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation �- tl�tr�i \� <br /> Domestic/private -� Drilled- Dia. of Well Casing ` y itt N <br /> Domestic/public Driven Gauge of Casing 2- <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic Protett_ion _ Rotary Type of GroutE- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> r $" <br /> PUMP INSTALLATION: Contractor AV 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . /7 State Work Done <br /> PUMP ,REPAIR: /7 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 GROUTING ANDA FINAL INSPECTIO <br /> SIGNED <br /> I <br /> PLOT LAN ON REVERSE SIDE <br /> FOR DEPART14ENT USE ONLY <br /> PHASE I J' <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE If I P ION PHASE III FINAL INSPECTION <br /> TXSPECTION BY ATE INSPECTION BY �':' DATE /o L <br /> E H 1426 Rev. 1-74 4/75 2M I <br />