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SAN JOAQUIN LOCAL HEALTH. DISTRICT 1 <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. <br /> ' I <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health 'Dis.trict 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 o`f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �,�,/� /n l :'l�C [/!.[1 Phone <br /> Address SI3r1y� City _oS'A .c,a� . <br /> t e r s r 7� 1 r,rj G'oratr c"�a:'s license <br /> Contractor s Name License # No.276664Phone <br /> J <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / J RECONDITION /_/ DESTRUCTION /-7- <br /> PUMP INSTALLATION / / PUMP REPAIR % / PUMP REPLACEMENT / <br /> Other / / r •ate.. r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGE PIT OTHER r <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 rf <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _-Gravel Pack .. Depth of- Grout-Seal— <br /> Cathodic <br /> f_ Grout-Seal,.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 _ / H.P. <br /> PUMP REPLACEMENT: //�tate Work Donej"L�lCll j <br /> PUMP-REPAIR: / J State Work Done <br /> DESTRUCTION OF. WELL: Well/_9 iam& kill' <br /> rJQ - 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G aD A NAL INSP CTION. <br /> SIGNED TITLE <br /> Zy „ DRAW POTPLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Sr j <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 14t/FING INSPECTION <br /> INSPECTION, BY, DATE d INSPECTION BY DATE <br /> i <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />