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r { 1 <br /> 'IV{/ SAN JOAQUTN LOCAlt I1AI,TH DISTRICT , 4-' <br /> FOFi.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, 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 Issued 2-;Zy- <br /> (Complete In Triplicate) <br /> Application is Qer�eby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. <br /> 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 �� Grc.�L` G{� ' CENSUS TRACT <br /> Owner's Name �� <br /> ✓i.�-,W�.� {� Phone <br /> e�3.5; -- <br /> Address ! " ( rt <br /> City <br /> Contractor's Name License Phone "� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/-7PUMP REPLACEMENT /7 -� <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 06 <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 I , <br /> L--Domestic/private --7--Drilled Dia. of Well Casing -1 Z, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gxavel Pack Depth of Grout Seal -� <br /> Cathodic Protection Gravel <br /> 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: . / / ' State Work Done <br /> PUMP '.REPAIR: /7 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. est-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND A F INSPE ON. <br /> SIGNED /l TITLE <br /> LO LAN REVERSE SIDE <br /> PHASE I D <br /> OR PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> FHASE I GROUT INSPECTION P I FINAL INSPECTION <br /> INSPECTION BY DATE - �S_ INSPECTION BY DATE - 5'7 S- <br /> E H 1426 Rev. 1-74 '",� vin + ,�ft � �►•!►/75 2M <br />