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SAN JOAQUIN LOCAL HEALTH DISTRICT ,! <br /> 'FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. t <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '/D <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,10-7,Y <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 Of t � CENSUS TRACT <br /> Owner's Name Phone �,�--'(, <br /> Address f►IZ City <br /> Contractor's Name �,�� L ff/ �Q License # ,60 Phone L2-v7 7 <br /> .. t . ..-.. -.i, A <br /> TYPE OF WORK (Check) : NEW WELL /,�// DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <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 USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial V Cable Tool Dia, of Well Excavation <br /> Domesti.cfprivate Drilled Dia, of Well Casing <br /> Domestic/publiczz <br /> 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 /> - -- r <br /> ----Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done y <br /> PUMP '.REPAIR: / / 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-He—alth District <br /> and the State of California pertaining-.to_or-regulating well "constructiori:� Within FIFTEEN DAYS <br /> after completion of my work on a new we31,_ I will furnish the San Joaquin Locai-Health 'District a <br /> WELL DRILLERS REPORT of the well and notify -fhem before putting the .well in use: The above <br /> information is true to the st of my knowledge and belie•.-.-j I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANP jk FIM INSPE ION. <br /> SIGNED - <br /> TITLE ��� u , •,i' <br /> (DRAW PLOT PLAN-ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2 <br /> APPLICATION ACCEPTED BY V -� DATE.--/ .- . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> °E H 1426 Rev. 1-74 117^ " 2M <br />