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1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (209) . 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9-15--7,7 <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 ,' CENSUS TRACT <br /> Owner's Name Phone i <br /> Address s City <br /> Contractor's Name J <br /> License Phone <br /> i! <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INST L�LATION PUMP REPAIR / / PUMP REPLACEMENT f-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -¢' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD—" CESSPOOL/SEEPAGE PIT/gP 0—'OTHER <br /> PROPERTY LT-NJMRIVATF, DOMESTIC WELL iV PUBLIC DOMESTIC WELL, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS •: <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing , f' / U <br /> Domestic/public T� Driven Gauge of Casing <br /> f 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 /> I f <br /> PUMP INSTALLATION: Contractor /1 <br /> Type of Pump _ H.P. <br /> P REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> e--�- „ . <br /> I hereby agreeto-comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State ,of- Californialpertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion­of-iny work on a new well, I will furnish the San Joaquin Local Health District a,_.., <br /> WELL DRILLERS REPORT—of the 'well;and nothem 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-,AND,A FINAL INSPECT <br /> t SIGNED : ' { . TITLE 4 <br /> RAW T ANON E FRSE SIDE) <br /> FOAPARTMENZ USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPT - : . , QIF-, E: DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i E H 1426 Rev. 1-74 �s <br />