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44s <br /> ` ,� Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,,/, 77 <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 /> JOB ADDRESS/LOCATION � � CENSUS TRACT <br /> Owner's Name tv ¢ � Phone <br /> Address A/ J�� � dL City <br /> Contractor's Name a,. , License # hone 4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION REPAIR/ / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V) <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 <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH.P. ✓ f <br /> PUMP REPLACEMENT: / / State Work .Done Il <br /> PUMP .RSR: 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 Dgs <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 thewell 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 GR UTING AND A FINAL SPE <br /> SIGN D TITLE <br /> 0 PLAN O VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPEC I N ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> a. <br /> CO <br /> E H 1426 Rev. 1-74 j177 2M <br />