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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. r r <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERM . Permit No. 2,7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued°$---J <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit- to construct <br /> r <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 1,�2 CENSUS TRACT <br /> Owner's Name Phone <br /> zo_ <br /> City . <br /> 4 Address <br /> Contractor's Name <br /> License ���� � Phone ( <br /> 3j-d <br /> f TYPE OF WORK (Check): NEW WELL /�� DEEPEN `/ / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION '/ / PUMP REPAIR / / PUMP REPLACEMENT 1_7 <br /> Other 1 <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 1 Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Sa <br /> v Irrigation Gravel Pack "Depth,,o£. Grout ,Seal <br /> Cathodic Protection ;.Rotary -s"*,Type of Grout <br /> Disposal Other " Other Information <br /> Geophysical , Surface Seal Installed BY: <br /> WW �I PUMP INSTALLATION: C ntrac r <br /> .TYP6 pf Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done . <br /> P <br /> State Work Done <br /> — -� I"y "ro ,sem' <br /> ES TRUCTION 0 WELL: Wel 'I} me�er Approximate Depth cin//C <br /> Describe Material and Procedure L 82 3-- ,4 �P <br /> I hereby agree to co ply with aLl laws and regulations of the San Joaquin Local ealth District <br /> t. and the State of Califo'i1a...pe-3.^"taining 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 G ING AND A Fi INSPECTION. <br /> SIGNED TITLE <br /> fDRAW PLAN ON RE FRSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE IDATE -Z8`7 <br /> t APPLICATION ACCEPTED BY <br /> I ADDITIONAL COMMENTS: <br /> PHASE -II GROUT INSPECTION PHASVJI&IFIN#V INSPECTION <br /> I INSPECTION BY . DATE / INSPECTION BY , •7-' <br /> u✓ V,f , L.Y►I C/1 miry O7ti /�" G{ .3Q <br /> E H-1426 Rev. 1-74 j �// _X., 3 �^ - (4 <br />