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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.L-i . ) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ..an__d the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION C�irL �� t!1 �,CENSUS TRACT <br /> i <br /> Owner's NamePhone <br /> • I <br /> Address °jToo <br /> y <br /> Contractor's Name � - ��-f--�ry�p✓ License #,,1(- 2--?7-3 Phone A� x-13 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_7 RECONDITION / I DESTRUCTION /_7 <br /> PUMP INSTALLATION ' PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK it, 0' SEWER LINES -1.6o 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 Drilled Dia. of Well Casing <br /> Domestic/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 �II <br /> Geophysical_ ; _ _ Surface Seal Installed By: nom' k <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: "/% State Work Done F <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 rue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A FI AL INSPECTIbN. � <br /> SIGNED TITLE <br /> „ DRAW PLAN 'ON REVEkSE SIDE) 7 71-1 7�77-1 ,:. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT PHASE III/FINAL INSPECTI ' <br /> INSPECTION BY 1'. DATE 2c3 INSPECTION BY �. -- - DATE �d / <br /> V76 2X� ;I <br /> E H 1426 Rev. 1-74 J <br />