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SAN JOAQUIN LOCAL 'HEALTH DISTRICT �L <br /> �i'�QF INUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f <br /> Telephone : (209) 466-6781 (/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued1-7-7,f <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health-District for a permit to construct i <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 w .®r CENSUS TRACT '. <br /> Owner's Name Phone <br /> Addressri [s ✓' City <br /> Contractor's Name License # ;*-?Z Phone L <br /> r1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION I I PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL,/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL � PUBLIC DOMESTIC WELL f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ] <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public -Driven Gauge of Casing CDS <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 ' <br /> Type of PumpAv H.P. <br /> 6 _ <br /> PUMP REPLACEMENT: / / State Work Done - -'-- ! <br /> E PUMP .REPAIR: / / State Work Done <br />� Approximate De th DESA•TRUCTION OF WELL; Well Diameter PP p <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 an 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 ofwl ge ' belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO_. I G AND A FINAL INS N. <br /> SIGNED _ ITLE / '.�'. <br /> RAW LOT LAN ON REVME SIDE). <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Q1 DATE <br /> ADDITIONAL COMMENTS.: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> 2M <br /> E H 1426 Rev. , 1-74 `° <br />