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' Y ,� - <br /> SAN JOAQUIN LO?�•AL HEALTH DISTRICT <br /> FOR•iOFFiCE USE. 1601 E. Hazelton�`ve.-, 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 L -7ri <br /> (Complete In Triplicate) <br /> Application is hereby inade' 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 = S CENSUS TRACT <br /> Owner's Name Phone -=--24jy <br /> Address , <br /> 9 city , e,k!�p n) _... <br /> _g 7 <br /> Contractors Name I License G <br /> ' y 1 Phone <br /> T'YPE'OF WORK (Check): NEW WELL L DEEPEN /_-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�PUMP REPLACEMENT- 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSP00L/.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 <br /> Excavation <br /> _1�= e Domestic/privat , Drilled Dia. of Well Casing <br /> Domestic/public. Driven Gauge of Casing <br /> -Irrigation ;. Gravel Pack Depth of Grout Seal o <br /> Cathodic Protection- Rotary Type of Grout ,de-,;.,� , ?� <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B • a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP IEPLACEMENT: / / State Work Done <br /> PUMP`REPAIR: ,; /-/ -State Work..Done_ <br /> ES;TRUCTION 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 Dis,ttict a <br /> WELL'DRILLERS REPORT of the well aid-notify them before putting..the. well in use. The above <br /> information is true to the-beat of my.knoiAedge_and belief. I WILL CALL FOR A GROUT`INSPECTION <br /> PRIOR -TO GROUTING AND -A FINAL INSPECTION. , <br /> SIGNEW. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R D T USE ONLY <br /> PHASE, I <br />.- APPLICATION ACCEPT Y ATE <br /> ;ADDITIONAL C NM : <br /> ,;. OUTINSPECTP I F AL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION Y DATE73 7- <br />' .•y ~E H 1426 Rev. 1-74 <br /> 1-74 2M <br />