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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �=6 p <br /> ;T THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3v_7G <br /> J (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 thpe� Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / C1 3 -4-a CENSUS TRACT <br /> Owner's Name Phone <br /> Address City` <br /> Contractor's Name License 40j ©T Phone 7 / <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/ / RECONDITION /_ DESTRUCTION /-7; <br /> PUMP INSTALLATION LF1 PUMP REPAIR/ / PUMP REPLACEMENT <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 °n <br /> Domestic/private Drilled Dia. of Well Casing til <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 4 J <br /> 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 C L FOR A GROUT INSPECTION <br /> PRIOR TO 9AOUTIY FINAL INSPECTION. <br /> SIGNED TITLE <br /> !"(DW PL PLAN ON REVERSE SIDE) ,.. <br /> FOR DEPART USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I 10/nNAL, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE 7�Z�-`�b <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />