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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` <br /> Telephone: - (209) 466-6781 ; 'y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued` `-3-75 <br /> (Complete In 'Triplicate) <br /> Application is hereby made to the San Joaquin Loeal_ Health District for a permit to construct <br /> and/or install the work herein described. T.his application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name -T 0 Phone 47 7 <br /> Address <br /> } city ' i <br /> ---_T <br /> Contractor's Name �( �Z171 License #, <br /> - Phone <br /> h. <br /> j TYPE OF WORK (Check): NEW WELL './? DEEPEN 1_7 RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION _X/ PUMP REPAIR`'/ PUMP REPLACEMENT %f <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK 0419, SEWER LINES ot, PIT PRIVY cy� . j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITLo 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 /> r <br /> Irrigation Irri <br /> —� g Gravel Pack_ Depth of .Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal ' ' - <br /> Other Information <br /> Geophysical r Surface Seal Installed BY: <br /> PUMP INSTALLATION:. Contractor PC <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT.if. / / State Work Done <br /> PUMP '.REPAIR: /-7 State Work Done ^J <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 Saii 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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED . <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> • <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III/FINAL INSPECTION <br /> DATE INSPECTION BY a DATE - 2 <br /> E H 1426 Rev. :Z-74 41 <br /> Y.. <br /> 1-74 .2 .. <br />