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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 .�.,,t-7- qp, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. < < `-�G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 94 --[ 7 <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 /> a-V /0"" E, q <br /> JOB ADDRESS/LOCATION E SUS TRACT <br /> W <br /> Y <br /> �{ <br /> Phone 1 �/ 7 <br /> Owner's 'Name �- " <br /> Address- Q (f, T City <br /> Contractor's Name &:'~,..e -�-� �' License ;'11(o.131-d Phone�( � � j k <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 'DEEPEN /_/ RECONDITION /_/ DESTRUCTION /`7 <br /> AL <br /> PUMP INSTALLATION X7 PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK fry .< ! SEWER LINES 1. d PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD f CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _P_UBLIC DOMESTIC WELL FE <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool nDia. of Well Excavation ' 1161, <br /> Domestic/private trilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of;. Casing <br /> Irrigation Gravel Pack Depth ofd.Grout Seal tS-b <br /> , ,.Cathodic Protection 'A Rotary � Type of Grout <br /> Disposal 'Other Other information <br /> Geophysical Surface Seal Installed By: <br /> 11 <br /> PUMP INSTALLATION: °'. Contractor 1, d 4D' <br /> Type of Pump I H.P. -�..r <br /> w <br /> PUMP REPLACEMENT: / / StAte W6rk-Done"""—`- <br /> PUMP .REPAIR: fi / State Work Done I, <br /> DESTRUCTION OF WELL: ,'+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 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 TO GR0 IN AN F AL INSPEQTION. <br /> SIGNED TITLE <br /> W- Ph T PLAN <br /> ''ON RE ERSE SIDE) <br /> f' FOR DEPARTMENT USE ONLY <br /> PHASE I /p�/ <br /> APPLICATION ACCEPTED BY �C DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY _ DATE 2 <br /> rf� 3/76 2M <br /> E H 1426 Rev. 1-74 <br />