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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR.OFFICE USE: ' 1601 E. Hazelton Ave. , •Stockton,. Calif. <br /> Telephone: (209)• 466-6781 <br /> APPLI{{CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.2 7-16b�f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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.. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -�°� ` r`Z , ( CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address Q <br /> City _ <br /> Contractor's Name [ �. .License Phone <br /> t i <br />( TYPE OF WORK (Check) : NEW WELL / DEEPEN '/_/ RECONDITION DESTRUCTION /7 a <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 PUBL ft-:DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTIONISPECIFICATIONS �.. <br /> Industrial + Cable Tool Dia.-'of Well EXGavat 6n. . <br /> Domestic/private 1 Drilled Dia.' of Well Casing <br /> Domestic/public j Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection C Rotary Type of Grout <br /> Disposal. 1' Other Other Information, <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of; Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP -.REPAIR: State Work Done <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 we11 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 TOG UTING AND A FINAL 1IN EC ION. <br /> SIGNED TITLE -�J7x.��,rJ <br /> - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />,PHASE I , ^7 <br />'APPLICATION ACCEPTED BY �f DATE 3 / 7 I <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �,(► 7 �' <br /> E H 1426 Rev. 1-74 A I/Z7 " 2M. � <br />