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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Haze*on A'Ve. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a f <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 SarL Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -1 -"- �,Ga.X'LCi2Gvcc� CENSUS TRACT <br /> Owner's Name (Te," e � .. Phone -� -3 2 <br /> Address 2trr" City, <br /> Contractor's Name Zee," License �•Z/� Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION /_/ DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Ze-*P 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 Cable Tool Dia. of Well Excavation lD <br /> 1�Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing /2 <br /> Irrigation Gravel Pack Depth of Grout Seal P <br /> Cathodic Protection ��Rotary Type of Grout 4�'��'�-<. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: L� <br /> PUMP INSTALLATION: Contractor lglez e- s <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 4ealth 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 <br /> WELL DRILLERS REPORT of e w 11 and notify them before putting the .well in use. The above <br /> information i test of my- 41owledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR A NAL IN N. ,/ <br /> SIGNED 1� -- TITLES 4,4 <br /> DRAW PLIOT PLAN ON REVERSE SIDE) 1; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - g <br /> ADDITIONAL COMMENTS: <br /> PHASE IT Gtntft INSPECTION PHASE III/FINAL INSPECTPRN <br /> INSPECTION BY \ DATE- '` _ INSPECTION BY DATE d75 <br /> E H 1426 Rev. 1-74 376 2M <br />