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Coy A � � SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOE OFF CE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) _466-6781 <br /> t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 CENSUS TRACT <br /> Owner s Name x .tj" Phone <br /> Address City <br /> Contractor's Name License # S-Phone c4lx -?x]-6 <br /> .. i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN 'L4 RECONDITION /T DESTRUCTION /7 <br /> PUMP INSTALLATION %/ PUMP REPAIR gl PUMP REPLACEMENT I-T <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 � 3 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing v <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP .REPAIR: / State Work Done- ^ o4 � .. M4 _. <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 '-constructi.on. 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 i <br /> information is true to the best of my-kno ledg and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FIN" I CT N. <br /> SIGNED TITLE . <br /> D Ph PLAN '0 RSE SIDE) . a•r''I; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASETeIGROUT INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE j2- a2 <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />