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r SAN JOAQdIN LOCAL HEALTH DISTRICT - <br /> FORfOFFICE USE: r / <br /> VVV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR: PUMP PERMIT Permit' No. 75-.4L/Qu} <br /> t a THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct ! <br /> rand/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 <br /> CENSUS TRACT <br /> owner's Name . Phone <br /> Addressl <br /> City <br /> Contractor's Name._ . _ <br /> License. #4��•Phone -v <br /> F - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /_7 DESTRUCTION <br /> PUMP INft CATION PUMP REPAIR /—/ PUMP REPLACEMENT 17 <br /> Other l/ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> s <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT OTHER \ <br /> PROPERTY 'LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL C� <br /> INTENDED_USE TYPE OF WELL CONSTRUCTION SPECIF <br /> IndustrialICATIONS <br /> : Cable Tool Dia. of Well Excavation < Ii v <br /> Domestic/private DrilledDia. of Well Casing er . j <br /> Domestic/public Driven Gauge of Casing f <br /> Irrigation- ' Gravel Pack Depth of Grout 'Se i <br /> Cathodic Protection —Rotary, - �-� Type of Grout <br /> Disposal k Other Other Information <br /> Geophysical <br /> q - Surface Seal. Installed By:. . <br /> PUMP INSTALLATION: Contractor <br /> Type •of Pump H.P. <br /> PUMP REPLACEMENT:_ State Wark,Dane <br /> ..PUMP :REPAIR: T /-7. State Work-Done <br /> ES;TRUCTION OF ,WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withall 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 f <br /> WELL DRILLERS REPORT of the we11 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 AND A FINAL-IINSPECTION. <br /> SIGNED [ TITLE <br /> # . (DRAW PLOT PLAN ON REVERSE SIDE <br /> _ FOR DEPARTMENT.USE LY <br /> PHASE I <br /> APPLICATION ACCEPTED BY0. . ;K DATE <br /> ADDITIONAL COMMENTS: <br /> I GROUT-4INSPE ION <br /> INSPECTION BY ��y`, _ _ DATE � � .7t� INSPECTION BP S IFIAL INSPECTION <br /> DATE Ej—��74] <br /> E H 1426 Rev. <br /> 1-74 <br /> . .. tea.• / �.. ,,.. <br />