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SAN JOAQUIN LOCAL HEALTH.DISTRICT ��`� <br /> fi FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, Zlo'-3,a2,rD <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,/ Date Issued <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 /> JOB ADDRESS/LOCATION _ � lr_"C CENSUS TRACT <br /> { <br /> Owner's Name Phone LJ/S <br /> Address EJ U N ' LL -- City <br /> Contractor's Name License # Phone s <br /> TYPE OF WORK (Check) : NEW WELL /_T DEEPEN / / RECONDITIONN t DESTRUCTION-/� <br /> PUMP INSTALLATION / / PUMP REPAIR /v/ PUMP REPLACEMENT I� <br /> Other <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 <br /> INTENDED USE ;TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable. Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing O <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 /> I <br /> PUMP REPLACEMENT: / / iState Work Done <br /> ' PUMP .REPAIR: R. ---State- Work-Done <br /> ,4 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 PROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> D W PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I ; <br /> APPLICATION 'ACCEPTED BY DATE <br /> ADDITIONAL -COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECT N <br /> f INSPECTION BY : DATE INSPECTION BY ad DATE <br /> V76 <br /> E H 1426 .Rev. 1-74 <br />