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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 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 4, --7- 77 <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 <br /> /of the San Joaquin Local Health District. ` <br /> JOB ADDRESS/LOCATION 7 b e4A-t CENSUS TRACT I <br /> Owner's Name Phone <br /> Address ? ,frit/ City <br /> Contractor's Name License # Phone 93a <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKCe.0 EWER LINES 6-00 IT PRIVY .412n� " <br /> SEWAGE DISPOSAL IELD CESSPO L/SEPPP PIT A� OTHER <br /> PROPERTY LINES PRIVATE DOMESTIC WELD_ UBLIC 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 /> I%1 <br /> Domestic/public Driven Gauge of Casing (1 <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ® Describe Material and Procedure <br /> thereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a 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 AN FINAL INSPECTION. <br /> SIGNED TITLE /��,tJT11OiL� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �^ <br /> R DEP TMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �W/ <br /> k PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' 7 <br /> 1177 o2M <br /> E H 1426 Rev. 1-74 <br />