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r <br /> 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. -7Z- L4zjd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �2 <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 Q f / r CENSUS TRACT <br /> Owner's Name Phone <br /> Address City h <br /> Contractor's Name License #,221(�l Phone <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- Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 <br /> rrigatian <br /> Gravel Pack be- p "of Grout Sea <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 - . r . _ - _ __. _... H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> 77 µ <br /> PUMP .REPAIR: /x/ . State Work Done <br /> F WELL: Well- Diameter Approximate Depth ` <br /> DESTRUCTION ,0 , --___ „ <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 true to thebes of my knowledge and belief. I WILL C L FOR A GROUT INSPECTION <br /> PRIOR TO GR T N FIN NSP I&�N. n <br /> SIGNED TITLE <br /> DRAW] P T PLAN ON REMSE SIDE) <br /> Fqj DEPARTMENT USE ONLY <br /> PHASE z 5--; ' <br /> APPLICATION ACCEPTED BY ,- DATE/.. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT410N <br /> INSPECTION BY DATE INSPECTION BY DATE -2-jv,?) <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />