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/f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: Z1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> /13 J-0 <br /> , THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -�tE-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 t�ea Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION e4 CENSUS TRACT <br /> Owner's Name Phone <br /> Address �zz.� � ��C,G(� City� �.'°` <br /> Contractor's Name A6 License # ;,9,/,,VvXPhone 6-5-1-793. <br /> TYPE OF WORK (Check) : NEW WELL /` % DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <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 / <br /> 9--Domestic/private k—Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing rt- <br /> Irrigation Gravel Pack Depth of Grout Seal 1Sd <br /> Cathodic Protection i-- 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 /> 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 INSPECT11, <br /> ON. <br /> PRIOR TO GROUTING D ,F NAL NS CTION. <br /> SIGNED TITLE <br /> _ DRAW PL T PLAN ON RE ,RSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P I OUT .INSPECTIO PHASE III/ INAL INSPECTION <br /> INSPECTION B DATE INSPECTION BY� __ _ DATE 2 _j �Z <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />