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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, dalif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .& 06/77 <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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ,� % ! CENSUS TRACT <br /> I <br /> Owner's Name 40eo Phone <br /> Address / Q •�E. City <br />. Contractor s Name /tel License # -M/90 Phone <br /> ti <br /> TYPE OF WORK (Check) : NEW WELL/—/ DEEPEN / / RECONDITION /, / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / f� PUMP .REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT " ` OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL I1 PUBLIC DOMESTIC WELL O <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 Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary', ' Type of Grout <br /> Disposal Other 4 Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INS.TALLATION:. Contractor <br /> Type of Pump H.P. t <br /> s <br /> PUMP REPLACEMENT:F ��`\ / / State Work Done ' # <br /> f PUMP .REPAIR: (. / / State Work Done <br /> DESJRUCTION-OF WELL: W611 -Diame`tdr = - a - Approximate Depth <br /> 'Describe Material sand, Procedure f� <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 td.46rtregulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wel1,'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 /> lin€ormation is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -iPRIOR TO OUTING ANA ffTINA12 INSPE ION. r, M <br /> SIGNED '„ t TITLE Y <br /> (DRAW:PLOT PLAN ON REVERSE SIDE) <br /> OR= DEPARTMENT USE ONLY <br /> 'PHASE I i <br /> APPLICATION ACCEPTED BY F DATE <br /> ADDITIONAL COMMENTS: M <br /> PHASE II GROUT SPECTION �jPHA .FINAIO INSPECTION <br /> INSPECTION BY E INSPECTION BY DATE 2,2 <br /> i f77. . 2Y�[ <br /> EH 1426 Rev. 1-74 - _.--- M <br />