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SAN JOAQUIN LOCAL HEALTH DISTRICT ,r 5 <br /> FORAFFIGE 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 Z 717� <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> E <br /> JOB ADDRESS/LOCATION d � CENSUS TRACT i <br /> Owner's Name /J P Phone ,S7(j <br /> Address � <br /> Citylee <br /> �F' <br /> Contractor's Name jat-Ze License Phone Lj�� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION /—T DESTRUCTION /_7 <br /> PUMP INSTALLATION,'/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 70 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 /6a <br /> Irrigation <br /> g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical -- <br /> -Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . /"J. ,-- <br /> Type of Pump ST H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 4ell, Approximate Depth ^ <br /> Describe Material and Procedure <br /> I hereby agree to comply wit all. law and regulations o 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 thea 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 GROU D F -O.N. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY \QOEP� cy) DATE <br /> ADDITIONAL COMMENTS: 14� <br /> PHASE II GROUT INSPECTION PHASE III,/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4dj&k DATEjr <br /> E H 1426 Rev. 1-74 1177 _ 2M <br />