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SAN JOAQUIN LOCAL HEALTH DfSTRI-GT - <br /> FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. f E ce <br /> Telephone (209) 7 466-6781-------' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ermit No. ,7ZLK,5,&2Ld <br /> L57 ia33-la <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED /Date Issued g_1S-?7 <br /> (Complete In Triplicate) <br /> Application is hereby de 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 f a� -� CENSUS TRACT <br /> Owner's Name _ � 2 �Q� �' Phone F3, / � <br /> Address © City <br /> Contractor's Name License # (: � ._ Phone . <br /> i <br />- TYPE OF WORK (Check)-:"''NEW-WELL 9 DEEPEN - / ' RECONDITION_/7 DESTRUCTION /_7 <br /> a PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> w Other J / <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 9 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 O <br /> Domestic/private Drilled Dia. of Well Casing/ <br /> Domestic/public Driven Gauge of Casing ,' e <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: c.c3 - • <br /> PUMP INSTALLATION: Contractor (� <br /> Type of Pump ? H.P. , d <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done ° e <br /> PUMP -.REPAIR: / /�. State Work Done <br /> F — <br /> DE°"TRUCTION 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 DAIS <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 GUUTJNG AND A NA INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _.2J ,�� DATE /� <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASEFINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY W ' DATE/ <br /> E H 1426 Rev. 1-74 J177 <br />