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�vl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: �"' 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T7_67 ;p�1 ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ^ ^T^j <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 ' CENSUS TRACT <br /> Owner's Name Phone <br /> Address City 'G �a0 <br /> Contractor's Name License # az� Phone y <br /> r <br /> TYPE OF WORK (Check) : NETnT, WE1L /E/-._._DEEPEN /_% RECONDITION / _ <br /> _/ DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /'V <br /> Other /7 <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANKS 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 /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public ,Driven Gauge of Casingi <br /> Irrigation -Gr'avel Pack -N Depth of Grout Seal r' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information f <br /> Geophysical Surf-ace Seal Installed By: <br /> PUMP INSTALLATION,. Contractor, <br /> �. Type"of Pump :.,. _ H.P. �t. <br /> State Work <br /> PUMP REPLACEMENT: .� Done <br /> PUMP .REPAIR:. , /�, / S.tate-` ork Done , { <br /> DESTRUCTION OF WELL: Well Diameter Approxifnate Depth <br /> Describe Material and Procedure <br /> F <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District� l <br /> and the State of California pertaining to or regulating well '-constructicn. 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..welf in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL-i FORA GROUT INSPECTION <br /> PRIOR TO GROUTING UD A RINA& INSPECTION. <br /> SIGNED TITLE a: <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> „ ... ,...,..... .. . _...,__ . .,,,__.� a <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASA II VFINAL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY f DATE WHIM <br /> • <br /> E H 1426 Rev. 1-74 - - ' 1177 2M <br />