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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE--'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> y Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7 75 i <br /> - 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued )-.;T- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <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 I/Ll f CENSUS TRACT <br /> Owner's Name Phonea� <br /> Address <br /> Contractor's Name 4� � .� r ` License Phone- Vs"-2 �/ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /,.-,DESTRUCTION.. <br /> _ UMP IiVSTALLA-kTON' /—/ P'U'N-P-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 �. <br /> Industrial Gable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - Irrigation Gravel Pack Depth of Grout Seal N <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Type of Pump f H.P.- <br /> PUMP REPLACEMENT: / State Work Done;;-�� <br /> PUMP .REPAIR: / / State Work Done <br /> DESJRUCTION 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 /> s <br /> information is true to the best of my knowledge and belief. I WILL C4-4 FOR A GROUT, INSPECTION <br /> PRIOR TO G UTING Y.D A FINAL INSPE ION. <br /> SIGNED . TITLE <br /> DRAW PL7T PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE l Z -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE-11 GROUT INSPECTION PIJAS /FIN NSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE/= c = <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />