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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOBLIXX <br /> rOFFICE <br /> USE, E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued k a -7 <br /> (Complete In Triplicate) 6 p <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 /> - 1 <br /> JOB ADDRESS/LOCATION R ' m �f ,, ._ CENSUS TRACT <br /> -r. <br /> Ownerts Name L., Phone 1;�4 SJ• „U <br /> Address J, City <br /> i <br /> Contractor's Name -- t e. P.0 mei License # / .U72 Phone G�s <br /> i. <br /> TYPE OF WORK (Check): NEW WELL '/-7 DEEPEN /? RECONDITION /� DESTRUCTION /-J <br /> PUMP INSTALLATION /—/ PUMP REPAIR /PUMP REPLACEMENT _ <br /> Other f� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEBPAGE 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 <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: / / State Work Done <br /> - <br /> PUMP :REPAIR: / State Work Done 6 "" <br /> RES;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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE 2 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY".----"- -- ------- <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> _ PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -,2- 77 <br /> % <br /> I t E H 1426 Rev. 1-74 1-74 2M <br />