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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 G� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 0 -13 <br /> (Complete In Triplicate) p(Vell ,P;rAj/1 77-12-7o <br /> Application is hereby made to the San Joaquin Local Health District for a pemit to construct/epa�� <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 ( �� © �. l�t - Q 1 CENSUS TRACT <br /> Owner's Name 0 Phone <br /> Address City Contractor's Name 2UY"bina License #& vqS Phone -a <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION /�? PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . Rotary Type of Grout , <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S, b n�i S�-b 4C H.P. 1 E� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DE&TRUCTION 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, INVfJCTION. <br /> SIGNED IZZ TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1/01 <br /> PHASE I <br /> APPLICATION ACCEPTED BY /tO %4DATE �lJ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF,.,III/FIIqAL INSPECTIO 57 <br /> INSPECTION BY DATE INSPECTION BY DATE 'S <br /> 12 <br /> I Z7 2M <br /> E H 1426 Rev. 1-74 <br />