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-� SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> F0__ O_FFICE USE: <br /> _ 1601 E. Hazelton Ave. , ,Stockton, Calif. s <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 D S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2 <br /> t F'• (Complete In Triplicate) <br /> Application is �iereby 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 .Sail Joaquin ' <br /> County' Ordinance, No. 1862 and the Rules and Regulations of the San Joaquin Local Health District• <br /> '2rz'� <br /> t CENSUS CT <br /> JOB ADDRESS/LOCATION - <br /> VIP <br /> Owne'r's Name L. 1 1 $4 Phone <br /> Address l:4 <br /> City <br /> i - __-.--License J- Phone 7 <br /> Contractor .s Name _ _ <br /> TYPE OF WORK (Check) : NEW WELL/ / , DEEPEN/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT /? } <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC TANK i .,SEWER,.LINES , . , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD.;-- ' CESSPOOL/SEEPAGE PIT OTHER a <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> `Industrial Cable,`Tool kf 'bia. of Well Excavation <br /> Domestic/private DrilleS D•1�a. of Well Casing— <br /> Domestic/public Driven ;,_,,-Gauge of Casing <br /> Irrigation--• '------- --- "`Gravel -Pack'"� �D"ep_th of-Grout Seal <br /> Ca_thodic Prote,cton,,,,_ - Ro.tary.___ ,..__� _Type_ <br /> of_- Grout <br /> Disposal Other : Other Information <br /> Geophysical . Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor r' <br /> Type of Pump W H.P.! PUMP REPLACEMENT: / / State Work`41)one <br /> u _ <br />�PUMP '.REPAIR: 3 /�/"-State Work" Done <br /> DESTRUCTION OF WELL: Well Diameter; + Approximate Depth <br /> Describe Mateiial and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health istxict , <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 /> SWELL DRILLERS RT -of the well andinotify them before putting the.-well in use. The above <br /> � informatio ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR-TO G A FINAL INSPECTION. <br /> SIGNED': 1 w° s TITLE �. . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �.` ^� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE � I 7 <br /> APPLICATION ACCEPTED" BY <br /> ADDITIONAL,COMMENTS: ` ,• . <br /> ` 'PHASE II GROUT INSPECTION _ ,;- PHASE III/ INAL INSPECTION <br /> 77 <br /> 1INSPECTION BY , . DATE INSPECTION BY ,� ATE <br /> 777— <br /> !1177 " 214 <br /> E H 1426 Rev. 1-74 - - <br />