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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /J 7-717 <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 D W. A Z <br /> CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address Cit <br /> an Joaq�ein umpCO. y � � - <br /> f Contractor's Name (Division a4 San�JC�� e�uapfiar Co.) y r License ��. Phone � { <br /> T g 0 Afy71 <br /> j <br /> TYPE OF WORK (Check) : NEW WELL:/. /, DEEPEN / / RECONDITION /�/ DESTRUCTION /_ + <br /> PUMJ' INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESq'IC WELL 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 <br /> Domestic/public Driven Gauge of Casin <br /> Irrigation �114. +VA Gravel„Pack- -Deptth„of Groutg Seal p <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _otherj1'Iuf.ormation <br /> Geophysical Surface Seal Installed By: ' <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /ti/ State Work Done Lc ? <br /> PUMP.REPA R {� <br /> State Work Done � 1- <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY f- <br /> ' <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY TATE INSPECTION BY -4:&2 DATE <br /> E H 1426 Rev. • 1-74 A �� - ,�%7 2M <br />