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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 77 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��3 uJ <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 Rules and Regulations /of the San Joaquin Local Health District. <br /> JOB ! S`9/LOCATION l ��' /: J CENSUS TRACT <br /> 5. 9 y <br /> Owner's Name , j /� Phone <br /> Address 2cr <br /> 4'5� -O City <br /> Contractor's Name License ��;!=�'l� hone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION / / DESTRUCTION /-7 <br /> PUMP INS AL ATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ` f SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD e �- CESSPOOL/SEEPA E PIT,� OTHER <br /> PROPERTY LIN15- eRIVATE DOMESTIC WELUBLIC 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 Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection F Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump a,P` - 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 TO GROUTING AND A FINAL INSPECTIO <br /> SIGNED ITLE �� [/3��J <br /> MP N REVERSE SIDE <br /> t DE AR ANT USE ONLY <br /> PHASE I <br /> APPLICATION ACC A/c 0 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY f/,.�, DATE 3 . 3 • � 7 INSPECTION BY 1;_0 DATE ,3-3 -] <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />