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SAN JOAQUIN -LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: e," 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] _ M,3?,0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 th ul Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,, C7o CENSUS TRACT <br /> Owner's Name Phone <br /> Address 1P_" ffp !L L City <br /> Contractor's Name L �� S License 41KZ:32 hone4" 9'010'/ <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 /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,X. <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing q <br /> Domestic/public Driven Gauge of Casing D\ <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 Do <br /> eu <br /> PUMP .REPAIR: /7 ' 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 INSPECT 4N <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDrr TITLEnl <br /> 'DRAW- PL T PLAN ON REVERSE SIDE - T,T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ DATE -,7 <br /> ADDITIONAL COMMENTS: r <br /> PHASE IF GROUT INSPECTION PHASE II/ SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 5�' <br /> .,. , 3/76 2M <br /> E H 1426 Rev. 1-74 <br />