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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1 OFFICE USE. 160 . E. Hazelton Ave. , Stockton, Calif. <br /> Telephone-. ' (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_5__,2.a1)11 <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 r r u�: P CENSUS TRACT <br /> Owner Is Name ` Phone .�;z -2 7-Sa <br /> Address <br /> ,)i city ¢ 5 -j, <br /> �o /✓ <br /> Contractors Name 1 D, dou- 4,L jy License #,2 7� Phone c`� <br /> TYPE OF WORK (Check): - NEW WELL /_7 DEEPEN /? RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP. REPAIR 0=P REPLACEMENT 7 <br /> Other <br /> DISTANCE TO NEAREST: „SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL OV <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 <br /> ` - Gauge of Casing <br /> Irriiia0ii' GraverPack -Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysicali _ - - Surf ace Seal Installed„By: <br /> PUMP �f1-cJ <br /> INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'REPAIR .State Work Done <br /> ZEST RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure T.. <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 completioW 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 FORA GROUT INSPECTION <br /> PRIOR To GPQUTING AND A F NAL INSPECTION. <br /> SIGNED TITLE <br /> &2L <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION PHASE-III/FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY A DATE � <br /> E H 1426 Rev. 1-74 I-74 2M <br />