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i SANJOAQUIN LOCAL HEALTH DI <br /> FOR,"OFFICE USE: ` STRICT <br /> I 1601 E. Hazelton Ave. , Stockton, Calif. <br /> p Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. h <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUEDDate Issued X.&6f77 . <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 San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � <br /> CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address J. <br /> City s� <br /> Contractor's Name License 0 Phone <br /> _X All <br /> it <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/7 RECONDITION %f DESTRUCTION / 7 w <br /> PUMP INSTALLATION REPAIR <br /> Other <br /> /� PUMP REPLACEMENT f <br /> I /% " <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> ,(D,LL 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 <br />� Domestic/private i; Drilled Dia. of Well Casing y , <br /> SDomestic <br /> /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 /> - <br /> Geophysical ' Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor , <br /> Type .of Pump H.P. <br /> A. <br /> PUMP REPLACEMENT: j//7 State Work Done <br /> . . .. it <br /> PUMP 'REPAIR: / / State Work Done <br />)E&TRUCTION OF WELL: a <br /> Well Diameter -- Approximate Depth <br /> Describe Material and Procedure <br /> L hereby agree to comply with all, laws and regulations of the San Joaquin Local Health District <br /> and -the State of Californiapertaining 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 /> TELL DRILLERS REPORT of the well and notify them before putting the...well .in.use.... .The above <br /> Lnformation is true to-the-best-of- my..knowledge and belief. I WILL CALL FOR-A GROUT INSPECTION <br />'RIOR TO GROUTING D A FINAL INSPECTION. , <br /> SIGNED ,�M, TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE iFOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE , <br /> 1DDITIONAL COMMENTS: q� ..- <br /> PRASE II GROUT INSPECTION PHASE IWM19INSPECTION <br /> LNSPECTION BY i!I DATE ` INSPECTION BY DATE 1 <br /> 9 H 1426 Rev. 1-74 i� r L h/75 .2M <br />