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s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> _ <br /> Telephone: (209) 466-6781 77- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedDEC AR W7 <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 egulations of the San Joaquin Local Health District. <br /> 133 �. I(fb P1v-;`- <br /> JOB ADDRESS/LOCATION �/a� 7' r t di annl CENSUS TRACT ^� <br /> Owner's Name draC O Phone r <br /> Address J 8 r2 r' f,ts' City 5 � _•'`� .-- <br /> Contractor's Name cf S [j License 4�1 Phone <br /> TYPE OF WORK (Check) : NEW WELL /L�' DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /pti� -t SEWER LINES/0' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEW( PRIVATE DOMPSTIC 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 (fir <br /> Cathodic Protection 4— Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B yes' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 CROUTIV. AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIIM) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , 7 <br /> APPLICATION ACCEPTED BY DATE�Z��J`�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II I PECTION PHASE III FINAL INSPECTION _y <br /> INSPECTION BY ATE INSPECTION BY - DATE -� / <br /> 6/77 _ 2M <br /> E H 1426 Rev. . 1--74 <br />