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V1601 <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> POF:.'OFFICE USE: E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7(I-- � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-�1-7C <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 Q1. CENSUS TRACT <br /> Owner's Name ? ME es, Phone 933 <br /> Address Wo City C "/ <br /> Contractor's Name Licensed? Phone ??020 <br /> TYPE OF WORK (Check) : NEW WELL/—f DEEPEN /_7 RECONDITION /7 DESTRUCTION f_7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � I <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal l <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 6 7 - 7 �. <br /> PUMPIREPAIR: . /_7 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 FORA GROUT IVaPECTION <br /> PRIOR TO GROUTW ANDA DINA1. INSPECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - - <br /> ADDITIONAL COMMENTS: <br /> _PHASE_ II GROUT INSPECTION PHA 41 AL INSPECTIO <br /> INSPECTION BY rDATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 --=- - h/75. 2M --- <br />