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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> --f—Or,-"OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 fJ I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?.�- T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> d{ (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 /> 30B ADDRESS/LOCATION �� <br /> -r fie. /� r CENSUS TRACT <br /> _i <br /> Owner's Name ! Phone Sc <br /> ,. <br /> Address ;. City , <br /> Contractor's Name f License Phone3,4s <br /> i <br /> TYPE OF WORK (Check) ; NEW WELL /_7 DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR., PUMP REPLACEMENT /-7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 'PROPERTY•LINE '. PRIVATE <br /> DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .Cable Tool Dia. of Well Excavation <br /> Domestic/private ' ,Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal U <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractors I <br /> Type of Pump H.P. IL6_ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /5State Work Done L"le <br /> } <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 to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO CROUTX% AND A FIN INSPECTION. <br /> SIGNED TITLE <br /> W <br /> POT 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 III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ! DATE -P-77� <br /> i <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 .. . <br />