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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 /> A 44 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued E �-? l <br /> f' (Complete In Triplicate) <br /> Application i 'rzereby 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 ' CENSUS TRACT <br /> Owner's Name Phone <br /> Addresscity r <br /> Contractor's Name �✓., �,c-«.�/ License iJ�.1:3 23 Phone3J�r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / J DESTRUCTION /_7 <br /> PUMP INSTALLATION J J PUMP REPAIR .��~PUMP REPLACEMENT /7 <br /> Other <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 1 <br /> j INTENDED-USE------ - - TYPE- OF WELL - - CONSTRUCTION SPECIFICATIONS (�1 <br /> Industrial. Cable Tool Dia, of .Well Excavation 4 <br /> w Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br />► Irr.igation. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information',; <br /> Geophysical _.. Surface Seal Installed By: <br /> PUMP INSTALLATION:-•---Contract r -� - <br /> Type of Pump - 7 .; H.P. Q - <br /> rw ' <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: p�j� State Work DoneAf�_O� <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 <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best of- my.kno. ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI A F INSPECTIO <br /> SIGNED TITLE <br /> D1tAW' PL T' PLAN ON RE EPSE SIDE) <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY &44 DATEFJ 71 I° <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> 'INSPECTION BY DATE INSPECTION BY DATE j <br /> 4 <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />