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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: --'- , 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 r/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDate Issued �3 7 <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 Jo4quin <br /> . County Ordinance No. 1862 andi. the Rules and Regulations of the' San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .. 0 / CENSUS TRAGI <br /> Owner's Name �,r.�� ✓ Phone <br /> Address � �"� t�� /i� / City //7 <br /> E . <br /> Contractor's Name License # A3- W hone <br /> _10- <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN / /� RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other / / -" <br />`DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIMATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. ,. } Cable Tool Dia, of,Well Excavation <br /> Domestic/private k , ; i Drilled Dia. of Well Casing <br /> Domestic/public I I Driven Gauge ofACasing <br /> Irrigation ! Gravel Pack Depth of"Grout Seal <br /> Cathodic Protection i Rotary Type •.of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> t <br /> PUMP INSTALLATION: Contractor � <br /> Type' of Pump H.P. <br /> PUMP REPLACEMENT: _ State Work Done <br />(PUMP .REPAIR: /K .tState Work Done �Off� : <br /> ..._.,� Itr�xA <br />,DES.TRUCTION OF WELL: Well Diametef'''" Approximate Depth <br /> Describ"e Material and Procedure <br /> II 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 onla 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 nowledge nd be ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL <br /> SIGNED TLE '.. it <br /> !� (WRAW LOT PLAN ON RE RSE SIDE) j <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION P I/ INAL INS PECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE /Q /c//77 <br /> E H 1426 Rev. 1 -74 2M <br />