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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.� .- 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION XG! (C ,J <br /> _ CENSUS TRACT <br /> Owner's dame ���.sr C �- c- `� Phone � 7 <br /> Address [.'- �� �� _� 3 City i6-Z<-A <br /> Contractor's Name ' <br /> �.-�.� �""-r����-'�'✓- License ��l -� �7� Phone 3� � ,�`\.� C. <br /> C <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN / / RECONDITION /—/I-` DESTRUCTION /-7 <br /> PUMP INSTALLATION / t/ PUMP REPAIR 4S�-7 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 Taal Dia. of Well=:Excavation <br /> _ Domestic/private Drilled Dia, of Well— <br /> Casing-1% <br /> Dome stic/public Driven 'Gauge of Casing <br /> F ` Irrigation Gravel Pack Depth of Grout 'Seal <br /> f Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> -,Geophysical ___� Surface Seal Installed B <br /> f <br /> PUMP INSTALLATION: Contractor <br /> k <br /> Type of Pump H.P. -t - <br /> PUMA REPLACEMENT: / / State Work Done <br /> 1 PUMP .REPAIR: /74�-- State Work Done rc <br /> n <br /> "-DES•TRUCTION 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 GRO TNG 4ND A INSPECTION. <br /> f SIGNED TITLE !t� <br /> .I W. <br /> PLVT PLAN ON RgVLFksE SIDE) , f <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 191--3/, <br /> ADDITIONAL COMMTS: <br /> PHASE II GROUT INSPECTION PHASE, I II FINAL INSPECTION <br /> r INSPECTION BY DATE INSPECTION BY ,�° ._. TE <br /> E H 1426 Rev. 1-74 . <br /> 3/76 2K <br />