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n � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE :.USE: (� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 4666781 + <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 ZX- 7 <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/LOCATIONXL q7e ry/ CENSUS TRACT <br /> Owner's Name Phone <br /> Address -e City ag A2 7AF 4Z <br /> k <br /> Contractor's Name License Phone C ; <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /� < <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT ' <br /> Other / / <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 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 /> T � � 'c <br /> � . <br /> .,Domestic/public . . Driven Gaug a-o£ Casin "- <br /> g �. <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: i <br /> PUMP INSTALLATION: Contractor 111U1VfejCgz 92 et, ply r'�--xzoe/ ev <br /> _T ' <br /> Type of Pump u � t '..£�..�i._.�-�._�,,,..— -- H.P. 2.a <br /> _ R? <br /> PUMP REPLACEMENT: / / State Work bone � <br /> PUMP .REPAIR: / J 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 best of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN2 AND A FINAL INSPECTION. <br /> SIGNED �_ TITLE iE <br /> (DRAW PLOT PLAN ON REVERSE SIDE7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 -/ 9'J <br /> ADDITIONAL COMMENTS: �� Y <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY f/J DATE <br /> : 177 <br /> E H 1426 Rev. 1-74 ". <br />