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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR OFFICE" USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a:y-7, <br /> i (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 /> the Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION i <br /> Phone <br /> Owner's Name <br /> / City//r�° i <br /> j Address (,� � a �. 7 ��f� <br /> Ot- <br /> License ��� aS�-.Phone <br /> Contractor's Name j <br /> TYPE OF WORK (Check) : NEW WELL/� DEEPEN / / RECONDITION_/ / DESTRUCTION JI <br /> PUMP INSTALLATION / PUMP REPAIR/_/ PUMP REPLACEMENT ,"'17 <br /> _Other <br /> -SEWER- LINES PIT PRIVY- <br /> DIS <br /> RIVY - r <br /> DISTANCE TO-NEAREST-:-�SEPTIC- TANK �- -�� <br /> SEWAGE DISPOSAL FIELD --CESSPOOL/SEEPAGE PIT ���' OTHER <br /> PROPERTY LINE - PRIVA E DOMESTIC WELL JPUBLIC DOMESTIC WELL <br /> E TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED US [� <br /> Industrial 3 Cable Tool Dia. of Well Excavation`' / Q� <br /> r�Drilled Dia. of Well Casing Q <br /> G tr-Domestic/private Gauge of Casing <br /> Domestic/public ,--� "" Driven g j <br /> Irrigation I GiaVel ,Pa,A Depth of Grout Seal <br /> Cathodic Protection I A--Rotary Type of Grout <br /> Disposalfx Other <br /> ' Other Information ' <br /> Geophysical # Surface Seal Installed B a <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of ,Pump I _ <br /> r ; <br /> PUMP REPLACEMENT: . / j State Work Done <br /> PUMP .REPAIR: / / ' State Work Done <br /> � t <br /> DESTRUCTION F WELL: W )Diameter F Approximate Depth <br /> _pescribe Mate" Dal 'an Pra edure <br /> I hereby��-t-��'�i¢iply with all Laws and �regula " ons of the San Joaquin Local Hea1t1T 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 /> k 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 4,JINAL INSPECTION. <br /> j SIGNED TITLE <br /> DRAW '3� 'F`PLAN 'ON REVERSE SIDE) <br /> OR <br /> PART <br /> MENT USE ONLY <br /> PHASE I +� DATE .� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: _ PRM /FIN INSPECTION <br /> PHASE I GROUT INSPECTION INSPECTION BY DATE -�- <br /> i <br /> INSPECTION BY DATE ` <br /> Z-7/7t <br /> � 3/76 ; 2M <br /> E H 1426 Rev.dl 74 <br />