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K" R. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave: , Stockton, Calif.' _ <br /> Telep4one: (209Y466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 'No. <br /> THIS _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Bate .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 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 /> . . <br /> JOE ADDRESS/LOCATION <br /> „ C CENSUS TRACTN'M <br /> Owner'skName -, j +�� . •-r , , �^� �� �c/ <br /> Phone 2S e <br /> Addressj , City A,' <br /> Contractor's Name <br /> . IAI e License Phone 2- I S I <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION / / DESTRUCTION /-7 <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other /% 4� <br /> DISTANCE TO NEAREST: SEPTIC TANKS-,:p '-1 SEWER LINES -- PIT PRIVY --- N <br /> SEWAGE. DISPOS��'' ,FIELD -- CESSPOOL/SEEPAGE PIT OTHER (� <br /> PROPERTY LINA-6 PRIVATE DOMESTIC WELL' �+ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation �Q <br /> Domestic/private Drilled Dia. of Well Casing 141 <br /> Domestic/public Driven Gauge of Casing <br /> 1 IrrigationGravel Pack Depth of Grout Seal (--N <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Geophysical Other Other Information <br /> Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor <br /> Type of -Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / StatejWork Done <br /> PUMP :REPAIR: /�/ State Work Done <br /> DES-TRUCTION' 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 n :tify them before putting the well in use.. The above <br /> information is true to th e of nowledge and belief. I WILL CALL FOR A GROUT' INSPECTION <br /> PRIOR TO G D A F NS <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 6-2-G Z 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S /IEINArINSPECTI <br /> INSPECTION BY DATE SPECTION BY ATE <br /> ito <br /> E H�1426 Rev. 1-74 ~.. �. - �. i�77 _ 2M . <br />