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V,111� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0fi70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.rA � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z,2_,7-7s- <br /> (Complete <br /> D-7 7s- <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 G':� (�/; ;c� CENSUS TRACT <br /> Owner's Name Phone <br /> Address u ? s �,A� {te t, U <br /> City <br /> f <br /> Contractor's Name License # PhoneL �/ <br /> TYPE OF WORK (Check): NEW WELL Ir-T DEEPEN /? RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /7 PUMP REPAIR1_7 PUMP REPLACEMENT F7 <br /> Other Ll <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 D0 S IC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 0' <br /> /Domestic/private r��Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L - Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump R.P. <br /> PUMP REPLACEMENT State Work Done <br /> PUMP 'REPAIR: %/ State Work Done <br /> DES-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 Distric <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 ta <br /> q in Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting_the..well in use... The above <br /> informatiop is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTI G AND A NAL INS CTI � -� <br /> SIGNED E <br /> DRAW T Ps 0 REVERS. SID <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Q-\0'75 <br /> ADDITIONAL COMMENTS: <br /> PXASE,jI GROUT INSPECTION PHASL I FINAL INSPECTION <br /> INSPECTION BY DATE -t0-15 INSPECTION BY DATE - 'S <br /> E H 1426 Rev. 1-74 2M <br />