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I SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> t FORInI7 <br /> OFFICE USE: 1601 E. Hazelton Ave.,, Stockton, Calif, 7 <br /> Telephone: (209) 466-6781 �` • <br /> 2 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7�- �AArl <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,;I-P-1-2,< <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 f ADDRESS/LOCATION� lb� J r CENSUS TRACT <br /> 1 <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Licensed Phone <br /> IL <br /> 1-7 <br /> TYPE OF W (Check) : MAIL '// / D EPEN /-RECONDI iiN _ DE TIS C/ / <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT / J <br /> Other.j/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 v .l <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public P Driven Gauge of ,Casing I <br /> Irrigation J Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor - <br /> Type off..Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done. { , <br /> DES-TRUCTION OF WELL: Well Dliameter F 7 <br /> 4 3 fJ a App ximate Depth <br /> Describe Materia and Procedur -0 ' <br /> I hereby agree to comply wit all law an re lat ns f,1the San Joaqui Local ea th Da trict . <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 beforeputting the -well in use. The above <br /> information is true to the-b s of my knowledge and belief. rI MILL' CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU IN AND A NSPECTION. <br /> SIGNE ' TITL <br /> D T' PLAN 'ON RE FRSE SII} i <br /> ? FO I),EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY N DATE —a <br /> ADDITIONAL COMMENTS: va <br /> PHASE II G N .� PHAS III/F NAL INSPECTION � <br /> INSPECTION BY DA INSPECTION BY DATE f <br /> E H 1426 Rev. 1-74 lr ��77 �lC � , , �2- -- �`, 3/76 2M <br />