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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 .!. r ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7?-3 6 Ia <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /:19-77 <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 Ugulationg of the San -Joaquin Local Health District. <br /> JOB ADDRESSAOCA I N -�� CENSUS TRACT <br /> Owner's Name Phone , <br /> Address Ci <br /> Contractor's Name �- r' <br /> License i6 ��3at Phona <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /7 'RECONDITI N /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR - PUMP REPLACEMENT 17 <br /> Other <br /> r <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 f_ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Caring <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> P .. Other Other Infariaation <br /> Geophysical Surface Seal' Installed By; <br /> PUMP INSTALLATION: Contractor . <br /> Type .of Pump H.P. , <br /> PUMP REPLACEMENT:. J / State Work Done <br /> 01 <br /> PUMP 'REPAIR: _j State Work Done <br /> } <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe-Material` and,Procedure <br /> I` I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4and 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 /> I 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 GROUT NG AND A FINAL INSPECT-ION. <br />( SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I` PHASE I - x <br /> APPLICATION ACCEPTED BY DATE <br />, ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION E I INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 h/75 2M <br />