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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: j�ZV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 61�p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-a 7 <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 /> 4 <br /> JOB ADDRESS/LOCATION _ t 'o 1 7h 1 t,, r' CENSUS TRACT 025- /?o•-t3 <br /> Owner's Name Phone-U 9-3( z Z <br /> Address D-, 0 City <br /> �1 <br /> Contractor's Name '10License P�2.3) Phone � Y3�. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / / RECONDITION f-1 DESTRUCTION /—T <br /> PUMP INSTALLATION /—/ PUMP REPAIR AU PUMP REPLACEMENT /—T <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 °p <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 <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: ., <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 i <br /> information is true to the best of my.. nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO W@UTWG AND AL INSPECTION. <br /> SIGNED TITLE <br /> W PTs T PLAN QN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ^6--x r`'T) �. <br /> E H 1426 Rev. I-74 <br /> 3/76 2M <br />