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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--678 . <br /> APPLICATION FOR:`WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDDa Issued —/1 7i <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a mit 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/Fs R' CENSUS TRACT <br /> Owner's Name <br /> %� ��f �� Phone , <br /> Address - �I City <br /> Contractor's Name f� License _!!M_,K Phone1� l f <br /> TYPE OF .WORK (Check) : NEW WELL / / DEEPEN / RECONdTION / / DESTRUCTION /_7 ' <br /> PUMP INSTALLATION / 7/r—PU TR REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TISPOSA e�d� SEWER LPRES C —P IT PRIVY <br /> r �ELI] CES�O�/SEEPAGE PTTFOTHER (. <br /> PROPERTY T,INE� 1°RTVATE DOMESTIC WELL��PUBLTC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL % CONSTRUCTION SPECIFICATIONS # <br /> Industrial Cable' Tool? Dia, .of Well Excavation ,/,frefi' <br /> Domestic/private Drilled Dia. of Wel,1. Casing ZA ii <br /> Domestic/public `—�{- Driven Gauge. of..-Casing; <br /> Irrigation A7 Grave, Pack Depth .of Grout Seal _ ur <br /> Cathodic Protection Rotary Type"'of_ Graut Aiii _ <br /> Disposal Ot /er Other ln:formation } <br /> Geophysical * ; Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracto <br /> Type of Pump. 31H.P. '_ ZS7 <br /> PUMP REPLACEMENT: / / S ate Work Done � <br /> PUMP -.REPAIR: / / State Work none <br /> DESTRUCTION OF WELL: W 1 Diameter Approximate Depth <br /> escribe Material and Procedure <br /> I hereby agree to co m ly with all Taws and regulations of the San Joaquin Local Health District <br /> and the State of Calfornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion o my work on a new well, I will -furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP RT of the well and notify them before putting the- well in use.. The above <br /> information is t -ue to the best of my knowledge and belief. I WILL CALL FOR A GR6UjT INSPECTION <br /> PRIOR TO GROUTI AND A FINAL INSPECTION. <br /> SIGNED E j <br /> ( LD ON REVERSE SIDE) a <br /> FOR BEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY EjJ DATE -` <br /> ADDITIONAL COMMENTS: F "" <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> a � ` t s <br /> E H 1426 Rev. . 1--74 '7e=607 /` , nf�77 2M <br />