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�a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone': (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7< J;/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' 71'76 <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 theines)�d Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION �� ( l CENSUS TRACT <br /> Owner's Name 4" n `- Phone <br /> Address 9 �'.(� W ! 1,6 City <br /> Contractor's Name _ ,�! License # L'PPhone r61, 7 <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 /> �► Domestic/private Drilled Dia. of Well Casing (A <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: Contractory <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done Ale, At) <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~ f my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL -I <br /> SIGNS TITLE ,, f <br /> . -M <br /> . I. <br /> RA P , T PLAN O E EBSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 95@UT INSPECTION PHASE/jIZIFINAL INSPECTIOlk <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />