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r _ SAN JOAQUIN LOCAL HEALTH DISTRICT <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. rJ <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issued <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 describeda 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 E CENSUS TRACT_ <br /> J <br /> . Owner's Name %^ G[ � LJ�� _ Phone <br /> Address s5 City 7� <br /> C i <br /> Contractor's Name (g-Q.- License # hone sJ <br /> TYPE OF WORK (Check) : NEW WELL 0 DEEPEN/_/ RECONDITION / / DESTRUCTION <br /> AL �( <br /> PUMP INSTLATION - PUMP REPAIR PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> " SEWAGE DISPOSAL FIELD/Q� CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'J-2-" 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 X <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -- <br /> ",. Cathodic Protection Rotary Type of Grout - fok:t I'l if <br /> Disposal Other Other Information <br /> Geophysical f�Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor226 ! <br /> Type! of Pump 7 H.P. :. <br /> State Work Done /t / �S /l �fJ .��1 Pr <br /> PUMP REPLACEMENT: S 1-- <br /> I ' elf v J,. m, AIA4� <br /> PUMP .REPAIR: j-/ State Work Done2djwc V <br /> DESTRUCTION OF WELL: Well Diameter Er 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 /> f WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ' information is true to ke of my knowledge and belief. I WILL CALF. FOR A GROUT INSPECTION <br /> PRIOR TO AROUXJ0 .AND F INSPECTION. <br /> TITLE <br /> SIGNED �- ,-------, -.is <br /> DRAW PI` T' PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY --- <br /> ADDITIONAL COMMENTS-.-- "- - <br /> 0&�__DATE <br /> INSPECTION t P I /FINAL INSPECTINSPECTION BY �.-�� - _ INSPECTION BY DATE M <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 - <br />