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-)74& SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> 70--E"OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , --_&� <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 Regulati of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT <br /> Z5,J)_� 51_A__�_�� J �tRACT <br /> po <br /> Owner's Name Phone <br /> Address 4 City <br /> Contractor's Name G�f Licensed/G <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / /� RECONDITIO / / DESTRUCTION /? <br /> PUMP INSTLATION PUMP REPAIR PUMP REPLACEMENT /� <br /> AL <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 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 Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Dan /2 -- - <br /> DESTRUCTION 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 /> 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 /> SIGNED TITLE <br /> DRAW PI <br /> )T'PLAN ON REVERSE SIDE) <br /> FOR DEP NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE =� <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSP CTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br /> 3/76 2M <br /> E H. 1426 Rev. 1-74 <br />