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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfirOFFICE USE: 1601 E. Hazelton Axe., §tockton, Calif. <br /> Telephone: (209)"466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedj6 <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 /> f <br /> Owner's Name _ � �.�r- d-® <br /> Phonemeg <br /> Address <br /> City -- it1Gt <br /> Contractor's Name06 . License # We Phone r 72.2 <br /> TYPE OF WORK (Check)s NEW WELL '/ DEEPEN/? RECONDITION / DESTRUCTION /'j <br /> PUMP INSTALLATIONL-7 PUMP REPAIR-L-7 PUMP REPLACEMBNT % j <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEP E� OTHERu�/ 7 <br /> PROPERTY LINE - PRIVATE DOMESTIC L' & — <br /> $TIC WELL <br /> INTENDED US$ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �� t` <br /> Domestic/private _.._ Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing i <br /> _Z/_ 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 <br /> H.P. <br /> PUMP REPLACEMENT: -,, State Work Done <br /> PUMPtREPAIR: jg State Work Done <br /> RES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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..wsll in.use.... The above <br /> information is true to the•best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> FRIOR TOG UTING AND FIN IN5PE iON. <br /> SIGNED _ ITLE C.: r� ,� <br /> DRAW P ON REVE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMS M: - <br /> PHASE II T INSPECTION PHAS II F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -1 <br /> -- <br /> E H 1426 Rev. 1-74 p <br /> - - U 4/75 2M <br />