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/ SAN JOAQUIN LOCAL HEALTH.DISTRICT � � 7 �U <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 60 -C <br /> r <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 9�� <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 .permiC 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 /> .4JOB ADDRESS/LOCATION 2 CENSUS TRACT <br /> Owner's Name- Phone <br /> Address City /y/e, � 4-.4 <br /> Contractor's Name AhzQ e 1,7%1 License # Phone '&�W <br /> i <br /> TYPE OF WORK (Check) . NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /7 t <br /> PUMP INSTALLATION / 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'WEL•L 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 /> T X f Irrigation Gravel Pack , ' t`kDepth of -Gro ut -Seal- <br /> Cathodic Protection.- - -Rotary Type of Grout 777 <br /> Disposal , Other Other Information <br /> Geophysical a Surface Seal Insi'a_ led B <br /> PUMP INSTALLATION; <br /> Contractor n kTca%% <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> } PUMP .REPAIR: '.. / / State Work Done _- <br /> i 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 .o€ 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 /> i PRIOR TO qViOUTING AND A FINAL INSPECTION. <br /> SIGNED - TITLE <br /> „ D W PhOT PLAN ON RE E'RSE SIDE) '' 1a <br /> # FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS E ; <br /> PHASE II GROUT INSPECTION PHASA III FINAL INSPECTION <br /> z INSPECTION BY DATE INSPECTION BY DATE 0,6---,?2 <br /> 3/76 <br /> E H 1426 Rev. 1-74 <br />