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SAN JOAQUIN LOCAL HEALTH DISTRICT Gl <br /> AT,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1'6 s <br /> Telephone: (209)466-6781 f,5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.71- ee <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued Lam_ <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 Joaqui <br /> r County Ordinance No. 1862 and the Rules and Regulations of. tthe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name /Z Phone& <br /> Address city <br /> ti <br /> Contractor's Name 17 ! LicenseZ -,Z 2 <br /> phone <br /> TYPE OF WORK (Check): NEW WELL LZ--P"-DEEPEN /? RECONDITION /-7 DESTRUCTION <br /> I PUMP INSTALLATION / / PUN? REPAIR 1-7 PUMP MEP�,Acm%H� <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK U SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDER USE TYPE OF :LL CONSTRUCTION SPECIFICATIONS <br /> F �- Industrial Cable Tool Dia. of Well Excavation <br /> Somestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing G. <br /> a1 : Irrigation R Gravel Pack Depth of Grout Seal <br /> r 1 Cathodic Protection IRotary Type of Grout <br /> sa <br /> Dispol t Other <br /> Disposal <br /> ..-- Other Information <br /> Geof Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor f <br /> Type 'of Pump <br /> t H.P. <br /> PUMP REPLACEMENT:. j//- State Work Done <br /> PUMP �REPAIR: <br /> /-7 State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before put ting.. 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 G TING FINAL) I SPECTION. <br /> SIGNED <br /> TITLE Z.0�/I <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 04z7zz:-- <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE IT, GROUT INSPECTIONINSPECTIPHASE II F AL INSPECTION <br /> ON BYE DATE ✓ INSPECTION B <br /> �., E H 1426 Rev. 1-74 6 <br />