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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE USE: 160.1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z �7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> F{ � (Complete In Triplicate) <br /> Application is.'-hereby made to the San Joaquin Local Health District for a permit to construct <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loand/or install the work herein described. This application is made in compliance with San Joaquin <br /> cal Health District. <br /> 1 JOB ADDRESS/LOCATION 1 <br /> 773 Al `i �r9hi7, CENSUS TRACT <br /> Owner's Name -- <br /> Phone 5//U__-.E31-6 % ',S' <br /> ;Address <br /> City <br /> Contractor's Name r License <br /> 2�Gaz Phone <br /> ;TYPE OF WORK (Check): NEW WELL /7 DEEPEN II.ECONDITION <br /> 4 DESTRUCTION <br /> PUMP IT3STALLATiON / / PUMP REPAIR / REPLACEMENT <br /> Other / / - <br /> DISTANCE TO NEAREST: SEPTICaTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> 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 �i <br /> Domestic/private - - Drilled Die. of Well Casing <br /> Domestic/.public Driven_ Gauge of Casing <br /> x: 'Irrigation Gravel, Pack Depth of Grout Seal ' <br /> Cathodic Protection Rotary Type of Grout fr <br /> Disposal Other Other Information <br /> Geophysical . . <br /> Surf ace Seal Installed B : <br /> PUMP INSTALLATION: Contractor f i <br /> . Type of Pump i H.P. <br /> PUMP REPLACEMENT: E7 State Work Done <br /> PUMP',.REPAIR: <br /> / / State Work Done _ ` -i• <br /> ES4RUCTION OF WELL: <br /> 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 oxi 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 T.NG D A IN PECTION. � <br /> SIGNED ? <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) _ F <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTSDATE_ /a_ <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY �, , . PHASE, -II,,FINAL INSPECTION <br /> - DATE 'INSPECTION BY DATE <br /> i E H 1426 Rev. 1-74 <br />