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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo-,,'OFFICE USE: (/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d <br /> THIS, PERMIT• EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r7a <br /> �.� <br /> (Complete- In Triplicate) <br /> Application is hereby made to-`the San Joaquin Local Health District for a permit to construct <br /> and/or instal:i . 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/-E� lD. iLj CENSUS TRACT <br /> � <br /> Owner's Name S ! Phone _ <br /> . .. . <br /> Address, ' i City <br /> Contractor's NameYA ' Licensee Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 a <br /> pc Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 �-SEWER INES d -PIT PRIVY <br /> e . <br /> -- <br /> �- - SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE Pl OTHER <br /> 1.l _ <br /> PROPERT.YTLIN PRIVATE DOMESTIC'WELZ -'-'P UBIIC DOMESTTC"WELI <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �� <br /> Industrial 1 Cable Tool Dia. of Well Excavation _Z& <br /> A----Domestic/private <br /> 74_w/, -.• -- Dia..__o.f._We11_Casing <br /> ,. ._. _ <br /> Domestic/publicDriven Gauge of Casing - - <br /> -Ir-rigation I Gravel Pack Depth of Grout Seal _may 2 <br /> Cathodic Protection F rotary Type of Grout — <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> 4 _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 101, i H.P. <br /> PUMP REPLACEMENT: / / State Work 'Done ' - i <br />' PUMP REPAIR: / / State Work Done <br /> � <br /> iDESTRUCTION OF WELL: Well Diameter Approximate. Depth <br /> Describe Material and Procedure `' <br /> A <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 thewell in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION ] <br /> TTTT.Fi. <br /> SIGNED ozo Ile <br /> (D PL T PL IX ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY I DATE .� 7 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT `INSPECTION PHASE III/FINAL INSPECTIO <br /> N It <br /> INSPECTION BY DATE `Z-C ' 'd INSPECTION BY DATE <br /> • .._ of 17 - 2M <br /> E H 1426 Rev. , 1-74 <br />