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A , 'SAN .JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466-6781 Fes, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � 4/ <br /> ..ti . <br /> S PERMIT_EXPIRES 1_ YEAR FROM D E ISSUED Date Issued -7-30-79.' <br /> THIS �� <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 /> Z5'S .S'. ,Hte,-j o-Y AO.p 1 e7--- (f-Z_e.--o <br /> JOB ADDRESS/LOCATION 2 r q _ - - _ CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> Contractor's Name License # U07 Phone <br /> TYPE OF WORK (Chock): NEW WELL /ff DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/-7-pump REPLACEMENT /7 <br /> Other /_7 <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 In <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 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 /> PUMP INSTALLATION.* Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUNP ,REPAIR: / / State Work Done . . <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 GVVTING AND FINAL JNSPECTION. <br /> i SIGNED 6,„ TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t E H 1426 Rev. 1-74 2M <br />