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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE­OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 f� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S -1- 71 <br /> -13f o f V u/F 7-4v (Complete In Triplicate) OSF -- zoo -0S/ <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 Rues and Rygulati of the San Local Health District. <br /> JOB ADDRESS/LOCATION / •,'�f CENSUS TRACT <br /> as <br /> Owner's Name <br /> r — Phone&P7 461, E� <br /> Address Cityf <br /> Contractor's Name License #&7j Phon&b/d9v'- 33 Y-7 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> ~�-�---Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (,u <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USS TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial j( Cable Tool Dia, of Well Excavation <br /> Domestic/private ^'� Drilled Dia. of Well Casing 49 <br /> ii <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation s 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 Done <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 ANDA FINAL INSPECTION. <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 GROUT INSPECTION PHASE III_IX,7INAL INSPECT <br /> INSPECTION BY DATE INSPECTION BY - DATE ZZZIZZ <br /> E H 1426 Rev. 1-74 1177 2% <br />