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.; SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> 0_ OFFICE .USE: Vol 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: (209) 466•-6781, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _` W. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date`4ls.sued <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 nayCENSUS TRACT <br /> Owner's Name,-'- j A C EN �`/%AA Phone <br /> Address- W 1' <br /> City _ �J�,A CSV CAX,{F <br /> Contractor's Name cense Phone. <br /> i TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ J PUMP REPLACEMENT /7 <br /> Other /_7 T" <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 I ME OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private A Drilled Dia, of Well Casing `A <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 'a �} <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' of <br /> Geophysical Surface Seal Installed B <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 ' <br /> 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 haquin Local Health--District <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 INSPECTION <br /> PRIOR TO GROUTING M_p A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W t, T PLAN ON REVERSE 5IDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br />` ADDITIONAL COMMENTS: 79_ <br /> PHASE II GROUT INSPECTION P SE I I/ NAL ZN CTION <br /> INSPECTION BY (} G��, DATE 5 > 2 INSPECTION BY DATE - 1` <br /> • i <br /> E H 1426 Rev. 1--74 376 2M , . <br />