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'' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFOR''OFFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> M-3124 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 7 <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 Sa Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION Com- <br /> ` � � CENSUS TRACT <br /> Owner's Name //+Si � i , <br /> I <br /> Phone - <br /> _--� <br /> Address City <br /> Contractor's Name { 1 ,✓►�-f �� f� <br /> C 7 License •���a <br /> # r&Phone <br /> ll <br /> 22f a <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/_/ RECONDITION /_/ 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 /> INTENDED USE <br /> PROPERT'Y.-FT;INE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL aE <br /> 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 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> kk Surface Seal Installed By-: <br /> PUMP INSTALLATION: Contractor• <br /> Type of lPump H.P. <br /> �- <br /> PUMP REPLACEMENT: State Work Done' o', D f <br /> f <br /> r I i <br /> �. <br /> 617 <br /> I <br /> PUMP .REPAIR: , -� Work Done` <br />)_E"I®T`RUCTION°'OF-WELL•:- Well-Diameter- — Approximate r <br /> DepthR�. ,. ,�.-•,- .,. <br /> Describe �Material and Procedure <br /> } E <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local. Health District <br /> tnd the State of California pertaining to or regulating well •construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />;ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GR UTING AN `-AIFTNAL INSP CT ON. <br />;IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br />'RASE I t& <br /> TPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: g --- <br /> PHASE II GROUT INSPECTI PHAS T /FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY D TE �- _4A 7f <br /> _ 1 <br /> E H 1426 Rev. 1-74 1,r77 : 2M I <br />