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SAN JOAQUIN LOCAL HEALTH DISTRICT -- '-- <br /> FO !OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone: (209) 466-6781. <br /> �k APPLICATION FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No., <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ig_7�1 <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 t e San Joaquin Local Health District. <br /> /.363 ., <br /> JOB ADDRESS/LOCATION s �AtAe6r CENSUS TRACT <br /> ' r <br /> Owner's Name , ., F Phone <br /> Address " flnL. City <br /> Contractor's Name �. ,.� License # 1 Phone <br /> TYPE OF WORK '(Check): NEW WELL /DEEPEN '/_7 RECONDITION /777 DESTRUCTION f7 <br /> j PUMP INSTALLATION / j PUMP REPAIR / / PUMP REPLACEMENT LY <br /> _ Other /_7 <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 able Tool Dia. of Well Excavation lo <br /> Domestic/private Drilled Dia. of Well Casing <br /> fDomestic/public 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 , i <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> :PUMP .REPAI&: = -I -State-Work--Donees-:.-� <br /> ,RES•-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 regulat.it:g: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 UOUTING 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 19 7 <br /> 1- ADDITIONAL COMMENTS: f <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> k INSPECTION BY DATE INSPECTION BY DATE i' 3 <br /> E H 1426 Rev, 1-74 <br /> 1-74 2M <br />