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_ Y 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. '7)— 1 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-11-7,7': <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 th an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> Contrac Name 1 <br /> License Phone <br /> i <br /> TYPE OF WORK (Chuck.): NEW WELL /7 DEEPEN -7 RECONDI DESTRUCTION <br /> PUMP INSTALLATION / / PUNP REPAIR /_7 PUMP REPLACEM M <br /> Other /� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT$SR <br /> PROPERTY LINE -PRIVATE DOMESTIC WELL PUBLIC MMSTIC nu <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We11. Excavation f ` <br /> Domestic/private Drilled Dia. of Well Casing _ `� <br /> Domestic/public Driven Gauge of Casing <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 aez <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . { / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ,...ter <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Kstrict <br /> and the State of California pertaining to or regulating well'-construction. Witkin FIYTX= VAI(A <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. TWILL CAITy FOR A GROUT I SPECTI: `, <br /> PRIOR TOG LUTING AND NAL INSPECTION. <br /> SIGNED TITLE <br /> W.. PLAN 'ON REV ttSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I VIA <br /> APPLICATION ACCEPTED BY - DATES <br /> ADDITIONAL DOM MTS: <br /> PHASE II ry-EPECTION P S I INSPECTION <br /> INSPECTION BY DATE _ INSPECTION DA -Z-7 <br /> 7� <br /> E H 1426 Rev. 1-74 + �[ <br />