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v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, ' Cal.if. <br /> t <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <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 01( &0E .`Trw� u, CENSUS TRACT <br /> Owner's Name 14a Phone P �3- 1(96 7 _ <br /> Address C 71 r <br /> City X rR ,kj <br /> Contractor's Name A) A 1 UA , C_.61, License # ' ' �; ��Phone 3 YS6 <br /> TYPE OF WORK (Check): NEW WELL"/—/ DEEPEN -/? RECONDITION /_7 DESTRUCTION /? - <br /> PUMP INSTALLATION -j PUMP REPAIR -/-7—PUMP REPLACEMENT /-7 <br /> Other / 7r `�" . . . . . . <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 8 `� <br /> -�� g Gravel Pads Depth of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout , <br /> DisposalOther Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump — 6H.P. (� <br /> PUMP REPLACEMENT: / / State Work Done Ui.s• 4eL.j-nn7-- .til OTO <br /> . f <br /> PUMP REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Descr.ibe .Material and Procedure <br /> k <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 co oar 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 .o£ 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 /> FOR DEPARTMENTUSE ONLY <br /> PHASE I _. — --- <br /> APPLICATION" ACCEPTED BY DATE /� '� <br /> ADDITIONAL COMMENTS: <br /> PHASE I UT INSPECTION wl <br /> PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H.1426 Rev. 1-74 !x/75 2M <br />