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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHiOF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s=5`�fp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED] Date Issued /a`3-ZS <br /> (Complete In Triplicate) i <br /> Application is hereby made to the Sat: 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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name -�� � _ Phone <br /> Addressu�� Ci <br /> t - <br /> 7 <br /> Contractor's Name 67dzL� � �T License r�;� Phone , < <br /> TYPE OF WORK (Check): NEW.,WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENTT <br /> /. <br /> Other <br /> 1 � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ;I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i 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 ;I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> I Disposal Other Other Information k <br /> Geophysical 'Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMPREPAIR: /7 State Work Done ,I <br /> ESJRUCTION 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 t best of my knowledge and belief. I WILL Ck1L FOR A 'GROUT INSPECTION <br /> PRIOR TO GR UTING AN F NAL .INSPECT ON. <br /> SIGNED TITLE-- - <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE It GROUT INSPECTION P I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - i�lb-74�_ <br /> E H 1426 Rev. 1-74 '� 1-74 2M <br />