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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. C� <br /> Telephone: (209) 466-6781YI ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 -3, , <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 and the Rules and Regulations ofthe an Joaquin Local Health District. <br /> �� y <br /> JOB ADDRESS/LOCATION 2C) (24� � � CENSUS TRACT <br /> Owner's Name � U/ �,�� �� Phone <br /> Address 6 /� . - - - — City <br /> Contractor's Name License # Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION DESTRUCTION 11-T - <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT <br /> Other E7 <br /> E 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 IMLr� <br /> INTENDED USB 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 i2,� <br /> Dk <br /> � <br /> Irrigation Gravel Pack Depth of Grout Seal :�2 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> j GeophysicalSurf-ace_Sea]�Installed By: <br /> PUMP INSTALLATION: Contractor }' . 4c1 <br /> Type of-=Pump S.P. <br /> PUMP REPLACEMENT: / / State Work Done- :. - <br /> PUMP :REPAIR: / A' State Work Done <br /> DESJRUCTION `OF WELL: Well Diameter Approximate Depth r - <br /> Describe Material and Procedure, <br /> k I ,'hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dis, ict AA <br /> I and the State of California pertaining to or regulating well'-construction. Within FIFTEEN RATS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District . <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. F WILL CALL FOR A GROUT INSPECTIg <br /> PRIOR TO GRQUTTNG AND A INME I PECTION. <br /> SIGNEDTITLE - <br /> W' PLAN ON SE SIDE <br /> ---FOR-.DEPARTMENT-USE-ONLY -T <br /> w PHASE I ; <br /> f APPLICATION 'ACCEPTED BY , DATE - 2 3 <br /> ADDITIONAL CONMTS: LTJ t hR� 4J <br /> t PHASE II _G INSPECTION PHASE II FINAL INSPECTION''. s <br /> INSPECTION BY D TE INSPECTION BY DATE <br /> d V76 29 , <br /> E H 1426 Rev. 1-74 <br />