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SAN JOAQUIN LOCAL HEALTH DISTRICT /�, iL 76 04(JAIWI�dkj, <br /> FGR:'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ►�l <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'J /�� <br /> II <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //r/ -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 /> E <br /> County Ordinance No. 1862 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name V-�ca.�pj License # Phone <br /> TYPE OF WORK (Check) : . NEW WELL / / DEEPEN %/ RECONDITION /_/ DESTRUCTION <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 p <br /> Industrial Cable Tool. Dia. of Well Excavation . 'v <br /> Domestic/private Drilled Dia.�..of Well Casing <br /> Domestic/publi.c 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 Insealled By-: <br /> A <br /> PUMP INSTALLATION: Contractor QWit/l~l' <br /> Type of Pump SU 3 �S� %3G� - H.P. <br /> PUMP REPLACEMENT: / / State Work Done�Irw ,17-73, v <br /> PUMP .REPAIR: / / State Work Done <br /> - t <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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED r- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ��� <br /> APPLICATION ACCEPTED- BY !/� F -- - - DATE <br /> ADDITIONAL COMMENTS: `- ► §- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT l <br /> E H 1426 <br /> Rev. - I-74 <br /> 0'177 M <br />