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to �- <br /> SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOk.OFFIC USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Permit No. 2,7— <br /> ?- THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 74.3-Z <br /> __ (Complete In Triplicate) <br /> Application is Aereby "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 �' <br /> ... , g � CENSUS TRACT <br /> Owner's 'Na'a :,• � a n <br /> Phone <br /> Address City <br /> Contractor's Name License # 7t-j Phone ' <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR LW PUMP REPLACEMENT /_7-Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC- TANK SEWER LINES PIT PRIVY „ Gt <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> f 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 Casing <br /> ' Irri± ation + <br />_ g Gravel Park Depth of Grout Seal <br /> Cathodic Protection Rotary. Type of Grout <br /> Disposal Other`�' Other Information <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractorcvzmmo&�IV z: � <br /> Type of Pump H.P. <br />'UMP REPLACEMENT: / / State Work Done <br />'UMP ,REPAIR: /fit/ State Work Done &ew , <br /> IES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe`Material and Procedure <br />[ hereby agree to comply with, all laws and regulations of the San Joaquin Local Health District � <br /> ind the State of California pertaining to or regulating well 'construciion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> Enformation is true to the bes of my kno�S ed and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO OUTING AND A FINAL I E IO . <br /> iIGNED cry. TITLE <br /> (D W PLOT PLAN ON VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />?HASE I <br /> 1PPLICATION ACCEPTED BY DA <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /FINAL INSPECTION <br /> LNSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 � � RM11 R 1177 _ <br />