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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE.OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 <br /> (Complete In Triplicate) <br /> (V <br /> Application ishereby-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 Ll 'a - CENSUS TRACT <br /> Owner's NameAl Phone ��� �1 <br /> Address Z Zv 4 City <br /> SCE? d/Y <br /> Contractor's NameajZZ � License Phone SjJ�S1SZ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL 1/ DEEPEN / / RECONDITION /_/ DESTRUCTION /_] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK/Op f SEWER LINES/Op PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE49 PRIVATE DOMESTIC WELLLa' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation odp <br /> Domestic/private Drilled Dia. of Well Casinga <br /> Domestic/public Driven Gauge of Casing <br /> - - Irrigation - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout — <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: k, �.a�, <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, 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 tot jgy <br /> knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ING D A <br /> SIGNED U TITLE awn[ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE,--.P- <br /> E <br /> ATE/2E H 1426 Rev. 1-74 1/77: _ ` 2M <br />