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t <br /> t,--__SAN JOAQUIN LOCAL HEAtTH. 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. 7 3,F }� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r� (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 Joaquii <br /> County Ordinance No. 1862 and the Rules and egulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ' PhoneX. <br /> Address City <br /> Contractor's Name 'r{ License 4ilPhoner ' - <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 p� <br /> _ ^ Domestic/private Drilled Dia, of Well Casing J <br /> Domestic/public Driven iGauge of .Ca"sing 1 <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 /> i <br /> PUMP-REPAIR:-- - / / State Work-,Done <br /> i <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> A <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 we11•construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 myknowledge and belief. I WILL GALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A FINAL INAPECLWN. t�I <br /> SIGNED TITL <br /> DRAW Pt, T' PLAN 'ON RE -RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I 1 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO NSPECTION PHASE/,j14/FINAJ,PHASE/,j14/FININSPECTION <br /> INSPECTION BY E INSPECTION BY DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />