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A i <br /> �/1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT'F0_R70FFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .26--U?10 i <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 SUS TRACT : <br /> Owner's Name <br /> Phone '.76 d —'l 33.s <br /> Address LU City <br /> Contractor's Name J License (d 3 Phone 4 <br /> � 3 <br /> TYPE OF WORK (Check): NEW WELL/% DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION "/-/ PUMP REPAIR /_7 PUMP REPLACEMENT y <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 /> Irrigatian:�__�;,.� . .w.� _'.-_.....--Gravel_P.ack .Depth-of.Grout.Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other �r Other Information h <br /> Geophysical Surface Seal Installed By. ' <br /> PUMP INSTALLATIONS Contractor <br /> Type of Pump H.P. _ <br /> PUMP REPLACEMENT: • /,orf` State Work Donee u'L-A <br /> w <br /> PUMP'.REPKIR: ] / *StZhei Work Done <br /> w � � <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 - <br /> information is true to the-best.of..my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION. <br /> PRIOR TO GROUT D A FIW INSPECT N. <br /> SIGNED TITLE <br /> f (DRAW PLT PLAN ON REVERSE SIDE <br /> F APARTMEWT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED,Z � DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION '' PHASE I INSPECTION ; <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> 'E H 1426 Rev. 1-74 r 11/75a-2M� <br />