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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 79 j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3 J <br /> � 7 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pe&it to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andtheRules and Regulations of the San Joaquin Local Health District. <br /> w <br /> JOB ADDRESS/LOCATION �J / ® /J -4, e CENSUS TRACT <br /> Owner's Name �f C� ��L C ' = Phone Ifsy (a- <br /> Address ' e;wj City <br /> Contractor's Name License # ' Phone 63v-7,,;, <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /-T DESTRUCTION / •-- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /� oQ <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7S` SEWER LINES ,So - 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 /> i--`Domestic/private 4—'Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing d''c. / <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection tom--Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter c� 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 G , TING AND A FI INSPECTION. <br /> SIGNED TITLE <br /> D T PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DAZ <br /> APPLICATION ACCEPTED BY ` <br /> ADDITIONAL COMMENTS: 1' <br /> PHASE IL G OU INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE l --7SV- �1 INSPECTION BY DATE 0 7 <br /> 3/7b <br /> E H 1426 Rev. 1-74 <br />