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SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOrrCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 ,7f f y� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED , Date Issued o� ' <br /> 7-7 <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 <br /> CENSUS TRACT <br /> ] p <br /> Owner's Name ���. A _ _ Phone <br /> Address ex— e C;tyAr<SC <br /> Contractor's Name Licensed Phone E <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION I / DESTRUCTION /7 <br /> PUMP INSTALLATION _X/ PUMP REPAIR / / PUMP REPLACEMENT / � + <br /> G <br /> Other <br /> ti. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES TIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHERi <br /> PROPERTY LINE .PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 /> Geophysical - D Surface Seal Installed By : <br /> -7-7-l yo <br /> PUMP INSTALLATION; Contractor 6, A11,0< _ <br />'C Type of Pump H.P. <br />' PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 T R TING MD A F AL INSPECTI N. <br /> SIGNED - <br /> �DKAW PLOT- PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1. DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECT FHA /FIN INSPECTION r� <br /> INSPECTION BY DATE INSPECTION BY ATE 2 d <br /> 677 2 <br /> E H 1426 Rev- . 1-74 <br />