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SAN JOAQUIN LOCAL HEALTH DISTRICT T TM <br /> FOR 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 �6 <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. 1$62 and the Rules and Regulati ns of the San•Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION M4CENSUS TRACT <br /> FD <br /> Owner's Name Phone 7,7 <br /> Address 44 <br /> City <br /> Contractor's Name License #&,( 3 Phone 6 <br /> ii <br /> TYPE OF WORK (Check) : NEW WELL 'X DEEPEN/% RECONDITION /—/ DESTRUCTION Z7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other L/ -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ > PIT PRIVY <br /> SEWAGE DISPOSAL FIELD {'CESSPOOL/SEEPAGE PTT OTHER ' <br /> PROPERTY LINE/`1�PRIVATE -DOMESTIC`JELL &d+PUBLIC DOMESTIC WELL : <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIO S <br /> Industrial Cable Tool Dia. of Well Excavation v S(D"' . <br /> Domestic/private {, Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 'V <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection• Rotary Type of Grout <br /> Disposal Other Other .Information <br /> Geophysical Surface Sea jnstalled BX: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - .< <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done t ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 3 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Cali pertaining to or regulating well -'construction. Within FIFTEEN DAYS <br /> after completion o my work n..a new well,, I w fu sh the San Joaquin, Local Health District a <br /> WELL DRILLERS REP T. of the el and notify em or utting the .well in.use. The above <br /> information is ue o the VE of- wf kn a nd ie FOR ROUT INSPECTION <br /> PRIOR TO GROUTI G AN INSP I <br /> SIGNEDTITLE I <br /> P PLAN 'ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BYDATE 2 s Z <br /> ADDITIONAL -COMM$NTS: <br /> P II ROUT INSPECTION iPHASE III17INAL-INSPECTIONZ. <br /> INSPECTION BY DATE INSPECTION BY ATE ;t ^ <br /> E H 1426 Bev. 1-74 3,/76 2M <br />