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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO& OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> i APPLXCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7-3o-J6 <br />€ i (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 ©AJ <br /> S� r "'icr: NSUS TRACT <br /> Owner's Name Al Phone , <br /> � - <br /> Address 5so S Cit � pd✓ <br /> Y N _ <br /> Contractor's Name p.., 4-Soticense # ,Z73oio Phone ',,?�38` 6 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/—/ RECONDITION /? DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR e PUMP REPLACEMENT /_7 <br /> Other l/ / <br /> DISTANCE TO NEAREST: SEPTIC :TANK SEWER LINES PIT PRIVY <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 . 1 Drilled ,, Dia: of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation `' ` I - Grave•1-Pack. --�.- Dep-thwof-Grqut Seal <br /> Cathodic Protection "f - 'Rotas Type ype of Grout <br /> Disposal --Other Other Information <br /> Geophysical Surface Seal Installed BY: -- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. - / / State Work Done <br /> PUMP .REPAIR: / State Work Done <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,'CI will furnish the Sari-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 GR UTING AND FINAL 'rINSPECTION. <br /> SIGNED <br /> TITLE*i <br /> ' D' W Pti T' PLAN 'ON REVERSE SIDE a i, 'A <br /> d <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 , <br /> APPLICATION ACCEPTED Bf:7���p DATE r G� <br /> ADDITIONAL COMMENTS: <br /> PHASE IY GROUT INSPECTION PWfgja_I/&0AL INSPECTION <br /> INSP.ECTION .BY ► DATE INSPECTION DATE <br /> E H 1426 Rev. 11-74 3/76 2M <br />