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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFIC S. 601 E. Hazelton -Ave. , Stockton, Calif. <br /> Telephone: (209) 46C--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 g Z? <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 ���' a.tv CENSUS TRACT <br /> I <br /> Owner's Name Phone <br /> Addresso8zief52-9Fe<?'- Cit <br /> Contractor's Name ,� J License IV451� ! Phone E <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /—/ DESTRUCTION /7 <br /> I <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /ZT, <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 pQ. ? <br /> Industrial Cable Tool Dia. of Well Excavation N <br /> Domestic/private Drilled Dia. of Well Casing � f <br /> Domestic/public Driven Gauge of Casing I <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 r [el d c/ 4c� 2 6 <br /> Type of Pump H.P. Z_ <br /> t <br /> PUMP REPLACEMENT <br /> / / State Work Done � <br /> I <br /> PUMP .REPAIR: I <br /> 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 wellin 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -�:-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION P S I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION B DA - _77 <br /> E H 1426Rev. 1-74 - if7�1 <br />