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CoSAN JOAQUIN LOCAL HEALTH DISTRICT ^_— <br /> FOROFVICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �S <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 70_ fuv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is herebymade <br /> 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/LOCATION7FI C1„�ri?id7� ,� CENSUS TRACT <br /> Owner's Names . ✓ t y' Phone <br /> Address City <br /> Contractor's Na License #/jjjh_Phoned <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTAL F NP REPAIR /_7 PUMP REPLACEMEIff <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <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 /> Irrigation/public Driven Gauge of Casing <br /> 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 �Vew <br /> Type of 'Pump Ors. H.P. i <br /> PUMP REPLACEMENT: / / State Work Done `Pux aa�7 � !I <br /> PUMP '.REPAIR: L7 State Work Done <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 knowledand-bc ief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GPXZING MkA FINAL INSPE ON. <br /> ;SIGHED TLE `--[moi-ate' <br /> D P OT PLAN O­NF <br /> V E SIDE <br /> MR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE -2 c--- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHA III FINAL INSPECTION/ <br /> INSPECTION BY DATE INSPECTION BY DA E <br /> '-E'H 1426 . Rev. 1-74 <br />