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/ SAN JOAQUIt,,.,-L•U1L HEALTH. DISTRICT <br /> F0t OFFrCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. { <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J,9, 7e <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 Sa Joaquin Local Health District. <br /> _1_z) CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's Name Phone <br /> Address / 7Q' 1' City <br /> Contractor's NameA"A , License �� �f Phone -1 f <br />` J <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION I / DESTRUCTION1fL� <br /> PUMP INSTALLATION_ / PUMP REPAIR / I PUMP REPLACEMENT I <br /> I <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK" �D ' 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> L---Domestic/private <br /> c--Drilled- Dia, of Well Casing <br /> Domestic/public Dri.ven� _ Gauge of Casing <br /> Irrigation 'Gravel Pack Depth of-Grout Seal 'Q <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> a <br /> E PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> F <br /> DESTRUCTION OF WELL: Well Diameter Approximate Deth^F <br /> Describe Material and Procedure,e <br /> tlrjG f� J <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 regulatiiig.well'-construction. Within FIFTEEN DAYS <br /> after`comple'tion of' my work- on aneva we11;'I-will furnish the San Joaquin 'Loca1"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 myknowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND-,A NAL INS CTION., <br /> SIGNED �. . TITLE <br /> DRA T LAN ON.RE 'RSE SIDE <br /> FOR DEPARTMENT USE ONLY I <br /> 4 PHASE I DATE / <br /> APPLICATION ACCEPTED BY kz� <br /> ADDITIONAL COMMENTS: <br /> P OUT INSPECTION P S I/FI INSPECTION <br /> s INSPECTION B DATE '�� INSPECTION B DATE <br /> t� ��-� ��• 3/76 2M <br /> E H1426 `Rev. 1-74 <br />