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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 274a 6a f0 i <br /> i <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 ` �- CENSUS TRACT <br /> Owner's Name � Phone36L 7 <br /> Address z2L2=S= City i <br /> Contractor's Name .�Q _ _ _ License Phone;]f- 2L <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN/ / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR ,/ _PUMP REPLACEMENT /_7 <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 <br /> Domestic/public Driven Gauge of Casingi <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 /> / C'l <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP .REPAIR: —State Work Done <br /> DESTRUCTION_ OF WELL: F Well Diameter Approximate Depth <br /> Describe Material and Procedure ! <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 putting the..well in use. The above f <br /> information is true to the-b st of. my... nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G D A FI INSPECT N. <br /> SIGNED TITLE <br /> =, RAWPtbT PLAN ON REVERSE SIDE) <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I • <br /> APPLICATION ACCEPTED BY DATES- l22 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION " <br /> INSPECTION BY DATEINSPECTION BY___3Z4 DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br />