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// SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> t <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FORtWELL CONSTRUCTION OR PUMP PERMIT Permit No. J6/- i3dx1' <br /> 1 <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 des cried. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 d the Ru s d Regulations f the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT N :3 CENSUS TRACT <br /> Owner's Name Phone 0;:P' //j <br /> Address Cit <br /> Contractor's Name Licensehone <br /> TYPE OF WORK (Check) : NEW WELL -/-7 DEEPEN/ / ~RECONDITION /? DESTRUCTION /� <br /> PUMP INSTALLATION/ / PUMP REPAIR `/ / PUMP REPLACEMENT C.a. <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 WELLCONSTRUCTION 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: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> PUMP REPLACEMENT: . � State Work Do � <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 INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED A per. TITLE <br /> • ,- D WI WT PLAN 'ON (SE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> `�_ <br /> APPLICATION ACCEPT B "w �y. c DATE <br /> ADDITIONAL CO <br /> P I OUT INSPECTION \\ P SE II' / NAL INSPECTION <br /> INSPECTI Y DATE - INSPECTIfl BY DATE <br /> E H 1426 Rev. 1-74 C 11 176 2K;-;,-" ,► <br />