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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> -TO-F,--'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 757tvo <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br />� d <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 R s and Regulationss of the San Joaquin- Local Health District. <br /> :4 <br /> JOB ADDRESS LOCATION � � G' CENSUS TRACT <br /> Owner's Na h`- 6.r" 6 5 <br /> Phone <br /> Address3_9±7 _7 <br /> Cit <br /> Contractor's Name License X6"3 73Phone .e9vo-.1 _ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_% RECONDITION DESTRUCTION/_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /_7Other / ---- <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 _n <br /> Industrial I Cable Tool Dia, of Well Excavation vi <br /> Domestic/private I DrilledAl <br /> Dia, of Well Casing , <br /> Domestic/public [ Driven Gauge of Casing <br /> Irrigation 1 , Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection t 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: / / State Work Done <br /> v.. �.. <br /> PUMP .REPAIR: :� State. Work Done'//- <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and' Procedure' ' <br /> I hereby agree to comply withlall 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 notifythem before <br /> 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 FINALIINSPECTION. <br /> SIGNEDTITLE <br /> f (DRAW LOTPLAN 'ON REVERSE SIDE) <br /> lyaDE NT USE ONLY <br /> PHASE I ! <br /> APPLICATION ACCEPT Y f <br /> IC DATE <br /> ADDITIONAL COMMENTS: �- 07 <br /> PHASE II 2ROUT INSPECTION PHASE III/FINAYINASECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r4L,,1Z , <br /> E H 1426 Rev. 1-74 . .. 3/76 2M.�' <br />