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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFOFFICE USE: <br /> 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 �s y7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date leaved 7-li'y <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��the S aJoaquin Local Health District. <br /> ->I• '�S <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION r:511Ji /1 if a <br /> .�' Phone <br /> Owner's Name Name .r, _A! <br /> City <br /> Address Car:-xt^�c"corse <br /> r R r r License G Na.275553 Phone <br /> Contractor's Name �• � 1 �+-=-�-- <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /� RECONDITION /-T DESTRUCTION r7 <br /> PUMP INSTALLATION PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE 1D 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 \p <br /> _ Domestic/public _ Drives Gauge oc" Casing <br /> _ <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation t <br /> Cathodic Protection _ Rotary Type of Grout V <br /> Other Other Information <br /> Disposal -- <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 9 ��LoZ�J H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done i <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 DAY: <br /> h the <br /> ` after completon of myWELL DRILLERSi <br /> iREPORT ofw <br /> wthe well and notify lthem lbefore sputting athe owell nLocal <br /> use.HeThe hDistrict a <br /> ork on a new well, above <br /> information is rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO 0 G AN F L IF ION. TITLE �::��2•!ri <br /> SIGNED - DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> �. PHASE I /. DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE I/F INSPECTION <br /> PHASE II ' T NSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> 3/76 2Pt <br /> E H 1426 Rev. 1-74 <br />