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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. <br /> THIS PERMIT EXPIRES I 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 <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address J- <br /> City..,,,--- pp.. <br /> Contractor's Name License #1623)_3 Phone�4-a_J _� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL J�V DEEPEN -/—/ RECONDITION 1_7 DESTRUCTION / 7 <br /> PUMP INSTALLATION /' PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other j/7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DYNES ; a PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 70 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 !� <br /> /Private Drilled Dia. of Well Casing '' U <br /> Domestic/public Driven Gauge of Casing /aZ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -Rotary \' <br /> y Type of Grout _ - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. <br /> Type of Pump <br /> H.P. <br /> _ f <br /> PUMP REPLACEMENT: / / State Work Done + <br /> PUMP -REPAIR: f / State Work Done <br /> DES•TRUCTION OF WELi;i -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 Distrfc ' <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAXS <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 kn ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG AND AFINAL INSPECT <br /> SIGNED <br /> TITLE � <br /> W P-0 f PLAN ON RMitSE SIDE (: <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMTS: , <br /> PHASE II GROUT INS- ECTIO . ZELL /PHASE I I NAL INSPECTION . <br /> INSPECTION BY DATE � � �SPg .IONS y _ DATE 3 77 <br /> J Jst�(•a �``�� �C r rnr �2� �Z 4J S 2e� .� ��r" �b <j � � :.. <br /> E H 1426 Rev. 1-74 S�t✓er 'sy `f X 76 2k!' <br />