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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�J�3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /O 3/"7 <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 ` r _ `/ ? a,%#a ,-, CENSUS TRACT <br /> Owner's Name � , � _- � Phone <br /> e <br /> Address ,� r y <br /> c�� Cit �; <br /> Contractor's Name C �`"` y �� , �-J License �� F� �" - Phone j <br /> TYPE OF WORK (Check) : NEW WELL j / DEEPEN / J RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / 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 <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///;--1 <br /> Type of Pump H.P. -i <br /> PUMP REPLACEMENT: / / State Work Done,'; ' ' ' <br /> i ._ F.:_.r (l,_. �' �: �;_ r'�� G� -f�x e <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure c\ <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distri <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 PIPAL ,INSPECTION. <br /> SIGNED /. t. .r� - ,,— TITLE <br /> IV (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEI5:;7/-,7�7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSITECTION PHA' I I/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ---F DATE <br /> r <br /> [� <br /> b/77 M <br /> E H 1426 Rev. - 1-74 <br /> .�'2 <br />