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• : • SAN JOAQUIN LOCAL. HEALTH DISTRICT ' <br /> -TOOFFICE USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> 0 Telephone: (209) 466-6181 + <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7L'7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S=1 3+7k <br /> n „ (Complete In Triplicate) <br /> Application is tereby 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 Joaq <br /> County Ordinance No. 1,862 and the Rules and Regulations of the San Joaquin Local Health Distric ,I <br /> JOB ADDRESS/LOCATION !3 CENSUS TRACT <br /> Owner's Name ' Phone j c�—4 <br /> Address /1� �O aC City A. <br /> Contractor's Name, IUB*License *L0103Phone -03T <br />-TYPE OF WORK (Check) : NEW WELL /DEEPEN / RECONDITION / / \DESTRUCTION /7 ' <br /> PUMP, INSTALLATION / UMP REPAIR / / PUMP ,REPLACEMENT .f_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKp SEWER LNES lo o PIT PRIVY <br /> r <br /> SEWAGE DISPSO AL FIELDIea CESSPOOL/SEEPAGE,.PIT,/ OTHER --' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE ,OF WELL CONSTRUCTION SPECIFICATIONS f. <br /> Industrial Cable Tool Dia. of Well Excavation ! <br /> 17 <br /> ;--V—omes tic/private Drilled Dia. of Well Casing ' s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of--Grout- Seal <br /> Cathodic Protection rotary Type of Grout - aAr-ro� iy[ T e- <br /> Disposal -Other Other Information <br /> Geophysical` Surf eal Installed B P. <br /> PUMP INSTALLATION; Contractor L. <br /> Type of Pump P. /% <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> rDES,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 Joaquifi 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 /> informat is true to the best o y knowledge and belief. I-WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A FIN E(1103, <br /> SIGNED <br /> W PLOT PLAN ON REVERSE SIDE) .--' <br /> FOR DEPARTMENT USE ONLY } <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' Lam' .-DATE-'s <br />` ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE- III/FINAL INSPECTION <br /> INSPECTION BY DATE ?`fes -7r 4_ INSPECTION BTY DATE <br /> 2M <br /> E H 1426 Rev. -1-74 <br />