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SAN .J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOR('OFFICE USE: 1601 E. Hazelton Ave. , -Stockton, Calif. <br /> Telephone: (209)_466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T- <br /> THIS,PERMIT EXPIRES 1,-YEAR FROM DATE ISSUED Date Issued 3 zr_;V <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 Rule and Regulations of the San Joaquin Local Health District. <br /> r� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> OwnerrsName i c r As-lb„zA..� � Phone <br /> Addressll.,L2l3 2 � _ : . ;s; City <br /> Contractor's Name �,w t--e , License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION - <br /> PUMP INSTALLATION A7 PUMP REPAIR / / PUMP REPLACEMENT-17 <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 /> a -Domestic/public P Driven' _ Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other WOthet`Information <br />� <br /> —Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I <br /> Type of:-Pump v t w Dr: e. H.P. <br /> PUMP REPLACEMENT: # ,/ / =.State,Work Done _ <br /> PUMP `.REPAIR: -"J C; ,11 T7 State,Work Done <br /> • f — <br /> -_ <br /> ES;TRUCTION 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- my-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE ALL. . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY, DATE 3,_je-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION P TI INAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION DATE <br /> E H 1426 Rev. 1-74 1-74 2M ` <br />