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CG SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:O FICE-.USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> �V/ t <br /> Telephone: (209) -46'6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> PERMIT',-.,,Permit No. <br /> ! <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �r _2L-26 <br /> (Complete In Triplicate) 0t-7'_ lqo-/q <br /> Application is hereby made to the San Joaquin Local health District fora 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 (gel +A4 A to r,4oo Qo S_S CENSUS TRACT <br /> VV <br /> Owners Name ! r <br /> Phone , <br /> Address a l m : a city <br /> Contractor's Na /� ..� . License #,, <br /> hone ;) <br /> TYPE OF WORK (Check) : NEW:WELL -/? DEEPEN /7 RECONDITION / f <br /> f DESTRUCTION / <br /> PUMP INSTALLATION -/—/ PUMP REPAIR Zg PUMP REPLACEMENT % f <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' PUBLIC DOMESTIC WELL <br /> =�INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation N <br /> D6mestic/private Drilled Dia. of Well Casing, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation-. Gravel Pack Depth of Grout Seal <br /> Cathodic Protec't'ion Rotary.- 'Type of Grout <br /> Disposal - .Other Other-Information r <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:: Contractor ,-� <br /> c ._ [ <br /> Type„of,Pump .r- H.P. <br /> PUMP`REPLACEMENT: F <br /> I / State Work Done <br /> PUMP :REPAIR: ,State Work Done <br /> DESTRUCTIONOF 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 /> 4ELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use... The above <br /> Lnformation is true to- the-best of m'y..knowl an be 'def. WILL CALL 'FOR A GROUT INSPECTION' <br />'RIOR TO NG ANDA :FINAL INSPE <br />>IGNED <br /> A <br /> AV <br /> DRAW PL LAN O ERSE SID <br /> FO D ARTMENT USE ONLY <br />'HA� S_E 2 <br />►?PLICATION- ACCEPTED BY DATE _-oOl <br /> 1DDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE III F A.T. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r ( <br /> E H 1426 Rev. 1-74 �. Y <br />