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/ <br /> 44 n �♦ <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 '? /v <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued gt�c <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 Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name \/t L TZ Phone / <br /> Address <br /> City <br /> Contractor's NameLicense # Phoney 7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN -/—/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /7 <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 r - <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 L� <br /> Cathodic ProtectionRotary Type o <br /> f 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 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 INSPECTIO <br /> PRIOR TO G TING ANDrA FJINAL INSPECTION. <br /> SIGNED TITLE <br /> -- .. -- DRAW PL T PLAN `ON RE FRSE SIDE __ I: <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: 10�1 17 <br /> PHASE II GROUT INSTICTION P II IN INSPECT N <br /> INSPECTION BY DATE INSPECTION BY � / DATEY1 7, <br /> 17,1 <br /> E H 1426 Rev. 1-74 3/76 2M <br />