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{ �? SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 1 7- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Z- <br /> rl�� y A). �-c.�-t i 1 (Complete In Triplicate) OSq-Z30 �o8' <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. 4 <br /> ,n '/ / <br /> JOB ADDRESS/LOCATION A-�c� CENSUS TRACT <br /> Phone <br /> Owner's Name <br /> Address City , <br /> �� I � �p r <br /> Contractor' s Name <br /> of License #16.1373 Phone <br /> TYPE OF WbRK (Check) : NEW WELL / / DEEPEN / / RECONDITION_ DESTRUCTION /? <br /> Ij <br /> PUMP 'INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other�I <br /> s 1 1 <br /> DISTANCE TO 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation_` - _ " '- ,Graye.l,Pack._. ____Depths.of .Grout -Seal �. <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type 'of Pump <br /> I! I . <br /> PUMP REPLACEMENT: IV—' State Work Done <br /> PUMP .REPAIR: / / ' State Work Done <br /> i' • <br /> DESTRUCTION:SApproximate Depth <br /> OF WELL: WellDiameter <br /> Describe Material and Pfocedure <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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> I PRIOR TO GR- TI AND OIN.AL INS,6ECTION. <br /> SIGNED TITLE <br /> RAW PL <br /> T PLAN 'ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Ij DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL i COMMENTS: ` <br /> PHASE III/FINAL INSPECTION <br /> IIi� PHASE II GROUT INSPECTION DATE <br /> ! INSPECTIONBY I DATE 'INSPECTION BY 7 _ <br /> 3/76 2M <br /> E H 1426 Rev. 1-74" <br />