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SAN JOAQUIN LOCAL. HEALTH DISTRICT i <br /> FOR OFFI USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q j �3 <br /> r rte+ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued - C7'7 <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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone , <br /> Address "�j Q o City <br /> License # ` hone <br /> Contractor's Name�o � � � �4�7 �' <br /> i` <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION /_/ DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION JV/ PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other <br /> O NEARS SEPTI <br /> DISTANCE T NEAREST: TANK SEWER LINES PIT PRIVY <br /> C C <br /> 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 <br /> Domestic/private Drilled Dia. of Well Casing O <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: Zh <br /> _ <br /> PUMP INSTALLATION: Contractor e.- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: J.aC/ State Work Done A c G <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 fi0 gOUTING AND A FINAL INSPECT ON. <br /> SIGNED TITLE <br /> (D W LOT PLAN ON RIERSE SIDE) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !� DATE 711e. ZZ <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION P IIJEINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 <br />