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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: -1601 E. Hazelton Ave. , Stockton, Calif. "Cy <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7J--LUL " <br /> i <br /> u 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 /> r 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/I` j to CENSUS TRACT <br /> Owner's Name Phone 3 <br /> Address (,tJ,'IZ,Ici City <br /> - <br /> Contractor's Name License #/_ J-373 Phone26S1 3 <br /> 1 <br /> TYPE OF WORD (Check) : NEW WELL/ / DEEPEN / J RECONDITION /_% DESTRUCTION /-7PUMP INSTALLATION '/ / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other 1/ / <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY 1 <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 t Cable Tool Dia, of Well Excavation <br /> Domestic/private t Drilled Dia, of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation i Gravel Pacii Depth of Grout Seal Ni <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTAI;IATION:" ` -Contractor - - - -- <br /> Pump of � <br /> H.P. <br /> PUMP REPLACEMENT: t <br /> / /, State Work Done <br /> PUMP .REPAIR: <br /> J/�-St ate Work Dt <br /> one <br /> I/ JIF <br /> DESTRUCTION OF WELL; 'Well D!.ameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall laws and regulations of the.,San Joaquin Local Health DJDAYS <br /> and the State of California pertaining to or regulating well '-construction. Within FIFTEi <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 /> informatio is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TIY13 AND A FIN INSPEC ON. <br /> SIGNED TITLE <br /> DRAW P T PLAN ON RE ERSE 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 <br /> i <br /> E H 1426 Rev. 1-74 3/76 2M <br />