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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. Z4-i/s9/Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /YaWe1-1 CENSUS TRACT <br /> Owner's Name Phone <br /> Address CK 01 =9L&=r� 70/ AG City <br /> Contractor's Name License #/6218 Phone�J <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /"7 <br /> PUMP INSTALLATION REPAIR/ / PUMP REPLACEMENT /7 <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 /> Domestic/private Drilled Dia. of Well Casing / " p <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation X_ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor 114&)6 <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. thp, San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after complon my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DR' L RS REPOR of the well d n them before putting the well in use. The above <br /> informat'on is tr o th bes k. le an a ief. I WILL CALL FO A GROUT INSPECTIO <br /> PRIOR TO GR A N N. <br /> SIGNED TITLE <br /> :.!(DRAW. PLTbT PLAN ON REV9RSE SIDE) <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I <br /> I __j <br /> APPLICATION ACCEPTED BY DATE ^ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRINSPECTION PHASE 14fifFINAIfINSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />