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T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 17/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 if /1-{-est ,. - NSUS TRACT <br /> Owner's Name <br /> Phone ? 3 1 ' <br /> Address City 1 <br /> dr <br /> Contractor's Name � <br /> License Jtl&j.37-3 Phone ( 2t . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r <br /> q <br /> Disposal Other Other Information_ F <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor t� <br /> H.P. <br /> PUMP REPLACEMENT: i / / State Work Done <br /> PUMP .REPAIR: /,'/--State Work Done <br /> DESTRUCTION OF'WELL: Well Diameter Approximate Depth <br />'r 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'con.struction. 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 tr a to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINff)Aq4 A FIN INSPECT ON. <br /> SIGNED ft— TITLE <br /> WW T PLAN `ON REVERSE SIDE I' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s 9 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTTON PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / _ DATE <br /> „ 3/76 2M <br /> E H 1426 Rev. 1-74 <br />