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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued la- ia-,z�— <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. 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 ry CENSUS TRACT <br /> Owner's Name .' Phone 7 Lc--13 0-1 <br /> Address �C 4 o 2j. City <br /> Contractor's Nam; %� F es . License keU,73 Phone - <br /> TYPIC OF WORK (Check): NEW WELL /_7 DEEPEN '/-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> Other 1/7 V:: <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERLLINES 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 i Cable Tool '.` Dia. ,of Well Excavation <br /> Domestic/private i Drilled Dia. "of Well Casing <br /> Domestic/public i Driven { Gauge-o'f Casing <br /> — 'Irrigation I Gravel pack Depth of Grout Seal <br /> Cathodic Protection r Rotary '`Type 4of Grout <br /> Disposal , - Ocher. =-- Other Information \ <br /> al_-- Surface Seal Installed By: _ \. <br /> PUMP INSTALLATION: Contractor S <br /> Type of Pump ev N- H.P. / C CN <br />' PUMP REPLACEMENT: / State Work Done i_ .¢ <br /> PUMP:REPAIR;._ . _ .State..Work Done <br /> ES-T - <br /> RUCTION OF WELL: Well 'Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> E I hereby agree to comply with 'ill laws and regulatidus of the San.Joaquin Local. Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after campletion '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 b`e`st of- my.knowledge and belief. I .WILL CALL FOR-A GROUT INSPECTION <br /> PRIOR TO GROU NG ANDA INAL INUECTION. <br /> SIGNED TITLE <br /> PLOT PLAN ON REVERSEtSIDE <br /> QR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r . DATE Al 1 <br /> E ADDITIONAL COMMENTS: s� <br /> j PHASE IIR T E ON �`t , PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ti E H 1426 Rev. 1-74 1-74 2M <br />