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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE 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 Issued17 <br /> (Complete In Triplicate) <br /> Application is .laereby 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 JoaquiLocal Health District. <br /> JOB ADDRESS/LOCATION D CENSUS TRACT <br /> Owner's Name h �a� Phone97,2 <br /> Address �_ 4A; + r0- City <br /> �0 <br /> Contractor's Name 2�iK/Cy� �' �Fa1 e S ase # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL f-1 DEEPEN/ / RECONDITION / / DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION � PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other '/ <br /> / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY c� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ,�J` <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal C� <br /> Cathodic Protection Rotary Type of Grout a <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump � H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate' Depth- R <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 GUMIK ANpa FI INSP CTI J <br /> SIGNED . . TITLE <br /> (DRAM PLUT PLAN ON REVERSE SIDE) ' k <br /> FOR DEPARTMgNT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/ lel--1 O <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH4SEjA/FINAj INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /z-7? <br /> E H 1426 Rev. 1-74 3/76 2m <br />