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6 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A/0. ILA E. CENSUS TRACT <br /> Owner's Name �P6-rL� Phone 3 <br /> f <br /> a <br /> Address r'ilJ l � City <br /> Contractor's Name ,. License.4/6 a 37-? Phone <br /> TYPE OF WORK (Check) :' NEW WELL/ / DEEPEN /_/ RECONDITION, / / DES.TRUCTION //_7PUMP INSTALLATION /'_/ PUMP REPAIR , _PUMP REPLACEMENT 17 a <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY: <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> —INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia, of Well Excavation <br /> Domestic/private t + Drilled Dia. of Well Casing T <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation [ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I 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: p� State Work Donees <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 ""� ..1 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROULNG AND A FI INSPECTI <br /> SIGNED TITLE <br /> DRAW-PI; T PLAN 'ON fflERSE SIDE)FOR DEPARTMENT ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY +` - DATElb-thl .. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/ INAL INSPECTION + <br /> INSPECTION BY DATE INSPECTION BY DATE 2,-Z <br /> E H 1426 Rev. 1-74: `3/76 2m <br />