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E <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE 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 3_ 7 7 <br /> L (Complete In Triplicate) 4 <br /> Application is hereby made tthe 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-a•'d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T-- )CENSUS TRACT C ?7-1 <br /> Owner's NameL ' � J9 �., <br /> Phone <br /> Address <br />• Address / ca3-6 Cit y <br /> Contractor's Name -!�j`� License �f� - 3fW g6 <br /> Phone <br /> TYPE OF WORK (Check) :` NEW WELL DEEPEN '/—/DEEPEN'/_/w RECONDITION /_7 DESTRUCTION /_7z <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 /> Domestic/public Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of. Grout Seal <br /> Cathodic Protection f Rotary Type of Grout i <br /> Disposal I Other <br /> Other .Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION; Cantr ' <br /> actor <br /> Type of Pump <br /> . � H.P. <br /> A �{ <br /> PUMP REPLACEMENT: / State Work Done {• <br /> PUMP .REPAIR: State -Work Do a <br /> � a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material `and Procedtiire <br /> -- <br /> I hereby agree to comply withjall 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 ona 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 G UTING AND A FINAL INSPECTION. <br /> SIGNED Bey TITLE <br /> D <br /> WL <br /> PLAN''ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY A <br /> � <br /> APPLICATION ACCEPTED BY DATE •. ��T� <br /> ADDITIONAL COMMENTS: + _ <br /> PHASE II GROUT INSPECTION P S /FIN INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATED!'" <br /> E H 1+26 Rev. 1-74 . <br /> __ _ _ 3/76 2M M <br />