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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -�1-701 <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 Iof the San Joaquin Local Health District,'. . <br /> JOB ADDRESS/LOCATION . JAY ��/1 CENSUS TRACT ' <br /> Owner's Name JA Al / Phone <br /> Address D City <br /> Contractor's Name License .�� Phone <br /> c' <br /> 'i <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/7 RECONDITION /7 DESTRUCTION L7 <br /> PUMP IN5TALLATION / / PUMP REPAIR 1-7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOLJSEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTEND D USE TYPE OF WELL w CONSTRUCTION SPECIFICATIONS : �•I, <br /> Industrial Cable Tool Dia, of Well, Excavation 27 <br /> Domestic/private Drilled Dia, of Well Casing 4� <br /> Domestic/public Driven 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 B i <br /> PUMP INSTALLATION: Q�( a � k <br /> Contractor 'Jo <br /> Type of Pump H,P, <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 'OF WELL: Well Diameter Approximate Depth {u`. <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 FIFTERN DATI; <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 GROUZING AND A F NAL NSPECTION. <br /> SIGNED TITLE <br /> W.. PLAN ON Ufft= SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE /D / <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL GOMMTS: /d i,.1 7A ceuoS- nre.vL <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY r 1c'> DATE 1044;-2,C INSPECTION BY DATE <br /> 3V7b <br /> E H 1426 Rev. 1-74 <br /> 2 try <br />