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--- - SAN JOAQUIN LOCAL HEALTH DISTRICT �- <br /> FOR 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 <br /> Date Issued <br /> (Complete In Triplicate) <br /> Applicatio .,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 Joaquia� <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ! Vis' CENSUS TRACT <br /> i <br /> Owner's Name . e Vis,. Phone <br /> Addresses ! !� City <br /> Contractors Name <br /> License #,907 yl Phone �-o <br /> t <br /> TYPE OF WORK (Check): NEW WELL % DEEPEN/7 RECONDITION /7 DESTRUCTION L <br /> PUMP INSTALLATION L> . PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Y PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT, 100-1A "OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WelljExcavation <br /> Domestic/private Drilled Dia. of Well -Casing ] <br /> E Domestic/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 <br /> Type of Pump H.P. / '+ <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP 'REPAIR: //7 State Work Done s <br /> ES-TRUCTION OF WELL Well Diaiueter <br /> Approximate epth <br /> Describe Material and Pr cedure .1 S-0 * <br /> eA- <br /> Ii hereby gree to comply with all 1 ws 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 puttingthe.-well in use.. The above <br /> information is true the-best of- my- knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU CTI <br /> SIGNED I - &CI—W-A TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE - ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I { <br /> APPLICATION ACCEPTED BY r DATE IZ 7S1 <br /> ADDITIONAL COMMENTS: <br /> P II 9R5&T INSPECTION PHASE I/FINa INSPECTION <br /> INSPECTION B t ' . DATE INSPECTION BY TE3/ - 7 <br /> E.H 1426 Rev. 1-74 vv4JV` ,..7G 7�4 <br />