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-" _ SAN JOAQUIN LOCAL HEALTH DISTRICT , }} <br /> FO OFFICE USE: (j 1601 E. Hazelton Ave. , Stockton, Calif. U" <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> J <br /> d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z ' <br /> (Complete In Triplicate) 283-0?o-- 0/ <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 Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Lo ;10,,h Disch17000 s, - erg-�e�� &V (' tom, <br /> JOB ADDRESS/LOCATION W7 / <br /> ,4"d ,j -[.�k <br /> Owner's Name / Phone <br /> Address f <br /> City <br /> Contractor's Namezeyl � <br /> License .��.- Phone ��e -72 / <br /> b <br /> t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN ' _/ RECONDITION /_7 - DESTRUCTION /_ <br /> PUMP INST LATION PUMP REPAIR / / PUMP REPLACEMENT <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 J <br /> Industrial Cab el Tool Dia, of Well Excavation 1.610 o <br /> Domestic/private Drilled Dia. of Well Casing e <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ° <br /> Cathodic Protection Rotary Type of Grout [ e. <br /> Disposal Other Other Information <br /> f. <br /> Geophysical Surface Seal Installed By: 25L6� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done \\Y <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF. WELL: Well Diameter <br /> pproximate 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 best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AN F AL_jILsPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE� �yLY <br /> ADDITIONAL COMMENTS: <br /> PHAS G S TION P SE FINAL INSPECTION <br /> INSPECTION BY ATE l� INSPECTION B ATE <br />: E H 1426 Rev. 1-74 �, v#m C6t�g E 7`77 -. 2 <br />