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_ 4. SAN JOAQUIN LOCAL--HEALTH DISTRICT "' a- <br /> . . <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> w 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 f <br /> (Complete In Triplicate) <br /> Application is Aereby 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. 186 and the Rules <br /> and Regulations the San Joaquin Local Health District. <br /> JOB ADD / {�/ <br /> RESS/LO TION � CENSUS TRACT <br /> Owner's Name Pho <br /> Address Y`/ C� j,�i ✓ <br /> Contractor's Namer <br /> .Licensee <br /> a <br /> -.TYPE OF WORK (Check) : NEW FWELL '/ / DEEPEN /�/ RECONDITION /�/ DESTRUCTIONt�//-7 y <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT> <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANTS SEWER LINES PIT PRIVY f A <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 /> Industria' `: ", , I Cable Tool Dia, of Well Excavation' <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public a ! Driven Gauge of Casing <br /> Irrigation 1 Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection t t Rotary Type of Grout <br /> Disposal i i 1 Other Other Information <br /> Geophysical ! Surface Seal Installed +By _ - - <br /> E 3 <br /> PUMP INSTALLATION: Contractor -- --� <br /> w <br /> Type';of Pump H.P. <br /> PUMP REPLACEMENT:. ' ( 'State Work Done <br /> PUMP ,REPAIR:�� <br /> State Work Dan <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply .withiall 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 GROUTING SAND A FINACINSPECTION. <br /> SIGNED TITLE <br /> f1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> . . FOR DEPARTAENT USE ONLY <br /> PHASE I � 4Ait_ <br /> APPLICATION ACCEPTED BY DATE // <br /> ADDITIONAL COMMENTS: t <br /> PHASE II. GROUT INSPECTION I PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 16 -Z-7 )8�' <br /> E H 1426 Rev. 1-74 1/77 2M <br />