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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone : (209) 466--6781 ]� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� �" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Ru es and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name 7' Phone f ` C` <br /> Address <br /> en 6a City �x �� <br /> Contractor's--Name , GJ So/1 — License Jdhone <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 /> Tydustrial Cable Tool Dia. ' of Well 'Excavation <br /> Domestic/private: . Drilled - .Dia.. of.Well Casing <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 /> Ggophysical Surface Seal. Installed By_- =� <br /> PUMP INSTALLATION: Contractor <br /> t Type of Pump H.P. <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP .REPAIR: / State Work Done L' <br /> IDESiRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure N <br /> I hereby agree to comply with all Jaws 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 JoaquinfiLocal-: Health Distiict 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 G TING AND A F AL IJ94BECTION. �- <br /> ISIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID4 <br /> a T ` -i :FOR`DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY C w r DATE orf- 7 <br /> 'ADDITIONAL COMMENTS: <br /> PHASE IGZqUT INSPECTION PHA51E I14/FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY // LA DATE / <br /> 1/Z7. _ 2M <br /> E H 1426 Rev. 1-74 _ _ _- - <br />