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SAN JOAQUIN LOCAL HEALTH 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. -q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2-A-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 i <br /> County Ordinance No. 1862 and the Rules and Regulations of the` San Joaquin Focal Health District. <br /> a � <br /> JOB ADDRESS/LOCATION � '� = y f / 106's _ CENSUS TRACT <br /> { <br /> Owner's Name Q Phone 82e- �fU 17 <br /> Address City j r-SCella <br /> y. <br /> I. <br /> Contractor's Name License �� a/D Phone ' <br /> A . . <br /> TYPE OF WORK_ (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /_/ DESTRUCTION <br /> -PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> .."" 0 tAer <br /> DISTANCE TO, NEAREST,: , SEPTIC TANK SEWER-- LIIGES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE a TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well `Excavation <br /> Domestic/private �V r ;Drilled Dia. of WellREasing <br /> Domestic/public ° Driven ' Gauge of Casing <br /> Irrigation.' _ Gravel Pack Depth of Grout Seal t„e <br /> Cathodic Protection Rotary Type of Grout .� <br /> Disposal Other s Other Information <br /> Geophysical ", Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump N. H.P. <br /> - <br />� PUMP REPLACEMENT: � State' Work Done � <br /> PUMP REPAIR: / / State,Work Done, <br /> DE&TRUCT_I_ON_ OF WELL.: Well Diameter Approximate Depth <br /> Describe+ Material and Procedure <br /> tl <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 GROJJqING AND A F NAL ZESPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -� <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE IrZ/FINAL INSPECTT N <br /> INSPECTION BY DATE INSPECTION BY{ 4Un6,r,. - DATE <br /> I I ZT2M <br /> E H 1426 Rev. 1-74 <br />