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r <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOB OFFICE=USE: ' �'�'' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedK 6„177 <br /> I (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. �2an4 the Rules and Re Mations o e San J again Local Health District. <br /> Al 4YA � <br /> JOB ADDRESS/LOCATION. CENSUS TRACT <br /> Owner's Name <br /> Phone 6 6 <br /> Address ( City <br /> Contractor's- Name 19. License #117.2gf Phone.?, &_ 7 <br /> TYPE,-OF WORK <br /> e-ck) : NEW WELL DEEPEN /� RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO 'NEAREST: SEPTIC TANK SEWER LINES - PIT`,-PRIVY <br /> SEWAGE-DISPOSAL -FIELD-. 3, •CESSPOOL/SEEPAGE PIT' - 'OTHER "" (14 <br /> PROPERTY LINE =^PRIVATE ,DOM-S TIC WELL PUBLIC DOMESTIC WELL,:..,.. O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS%1 <br /> Industrial 11" 1 Cab 1e Tool Dia, of Well Excavation dr4 : <br /> Domestic/private 1 Drilled Dia, of Well,,Caging , <br /> Domestic/public 14, f Driven Gauge o ;�.Casing` <br /> _Lef�Trrigation 1-1) Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1 <br /> Disposal ` Other Other Information <br /> Geophysical Surf ace Seal Installed B <br /> x <br /> ra <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT <br /> / / State Work Done <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 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 ANDA FINALIINSPECTION. <br /> SIGNED TITLE i <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION ACCEPTED BY DATE 6 , <br /> ADDITIONAL COMMENTS; I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY f ATE INSPEC ON BY DATE/,► _23-1 <br /> E H 1426 Rev. 1-74 G 117.7 _ 2M j` <br />