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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh;OFFICE USE: / 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s- 711d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE JSSUED Date Issued /1J7-7S' <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/L. CENSUS TRACT <br /> Owner's-Name AA Phone - <br /> Address,. <br /> hone Address,. ZZ n City '_ <br /> Contractor's Name License ; ,��IO�/,3 Phone2-4931 <br /> f' TYPE OF_WORK (Check) : NEW WELL '/7r DEEPEN '/77 RECONDITION ��° DESTRUCTION /- <br /> TA <br /> PUMP INSLLATION `/ / PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> Other <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 s N, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ ✓ Domestic/private Drilled � Dia. of Well Casing <br /> Domestic/public Driven d it Gauge of Casing - <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection , ✓ . Rotary Type of Grout ' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pumps W H.P. �. <br /> PUMP REPLACEMENT: / / State Worm Done <br /> PUMP ,REPAIR: —_tiState Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth € <br /> Describe Material and Procedure <br /> 4 <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 /> PRIOR TOG OUTING AND WINAL _ZNSkCTjON. <br /> SIGNED ; 'TITLE <br /> (DW PLOT LAN ON RE SE SIDE)( <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT D BY'}' DATE <br /> ADDITIONAL CO S:// <br /> c- E 1I GROUT INSPECTION P NAL INSPECT N r <br /> INSPECTIt�iV_, DATE S INSPECTI DATE <br /> h <br /> E H 1426 Rev. 1-74 _ x,/75 2M�"' �"� <br />