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30 <br /> SAN JOAQUIN 10CAL HEALTH DISTRICT <br /> FOE OFFICE USE: i ,. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> L' 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 gate-2,1 <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 �� ���"�/ �, � CENSUS TRACT <br /> Owner's Name Phone ' -, _ <br /> Address f!,: % / City, <br /> Contractor's Name License ��.7RG7b"/3Phone � <br /> a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 ia2. <br /> Domestic/private Drilled Dia. of Well Casings N <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection k­1- Rotary Type of Grout <br /> Disposal Other Other Information 61 <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP .REPAIR: /77 State Work Done <br /> DES •TRUCTION OF WELLell Dia eter T A p oximate Depth VO <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 GRO TING AND A FINAL INSPECTION. <br /> SIGNED _ TITLE <br /> (DRAW PIXT PLAN ON REVERSE SIDE' rR; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _✓ � <br /> APPLICATION ACCEPTED BY �i�D� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/FIN INSPECTION / <br /> INSPEC ION BY DATE — - INSPECTT '" DATE -/-76 <br /> a 3/76 2M <br /> E H 1426 Rev. 1-74 <br />