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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 77-���� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s.Po.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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 942 pt,t' , jo �� � �,� � CENSUS TRACT <br /> Owner's Name "V Phone <br /> Address 4-70 0 4,e, ��. �� City p 0 <br /> Contractor's Name License 3,Slhone 4k 721,7�. <br /> TYPE OF WORK (Check): NEW WELL L7 DEEPEN/7 RECONDITION /7 DESTRUCTION /7PUMP INSTALLATION El PUMP REPAIR /U/ PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT 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 /> _L 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 k- <br /> Type ofPump H.P. b U <br /> PUMP REPLACEMENT: / / State Work Done <br /> UMP ,.REPAIR: ZX7 State Work Done Cit A01t 6 . '` rf <br /> ,?SES®RUCTION 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 y 1 and b ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL INSPE N. <br /> SIGNED y ITLE _ <br /> W LAN ON RSE SIDE <br /> — <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 5 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION` <br /> INSPECTION BY DATE INSPECTION BY DATE .zy. 71 <br /> ti E H 1426 Rev. 1-74 <br /> 1-74 2M <br />