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1 4N <br /> J _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ..a OFFICE .UM: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT p ` t No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 ,z, 7 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. 1862and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I�� CENSUS TNACT- <br /> Owner's Name Cif 1t .� PhoneP'`!I <br /> Address U <br /> City <br />�f Contractor's Name frg .j-c�. 7 -License # 9A;,9A Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_% RECONDITION_ /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /'/ PUMP UpLACAMl ff <br /> Other f-1 <br /> t �' -•nom' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 0rHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL----"- <br /> INTENDED <br /> USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ; \. <br /> Industrial Cable Tool Dia. �of Well Excavation <br /> Domestic/private Drilled Dia. -of'Well Easing �v <br /> Domestic/public Driven Gauge of Cas ►g Q <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 7Rotary ` _Type.of Grout <br /> —Disposal ! Other _ Other-Iriformatian <br /> Geophysical _ Surface-Zeal Installed B : <br /> f <br /> PUMP INSTALLATION: Contractor a/ <br /> Type of POW i <br /> . H.P. <br /> PUMP REPLACEMENT: State Work Done -.c.c. mac. <br /> PUMP -REPAIR: - ' State— { <br /> Work Done <br /> DESTRUCTION OF WELL: Well Diameter i <br />--� te • <br /> Describe Material and ProcedureApproximaDepth " <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 "_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 INSPECTIO PHAS�IM/FINAJL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ZZ <br /> E H 1426 Rev. 1-74 <br />