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•1. � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFLCE USE: 1601 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 f <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 j S,? I zzg a V CENSUS TRACT <br /> Owner's Name , �uPhone3 <br /> Address _ .', 2 14I&rzV _ _- City Esegs&,e <br /> Contractor's Name < License 4>' Phonef - <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/—/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTAL TION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES :5f3# - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINW12' RIVATE DOMESTIC WELL _f PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial X Cable Tool Dia. of Well Excavation 0'/ -- <br /> Domestic/private Drilled Dia, of Well Casing n (p <br /> Domestic/public Driven Gauge of Casing s?,yi� <br /> Irrigation Gravel Pack Depth of Grout. Seal 0 f <br /> Cathodic Protection Rotary Type of Grout �- <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed By: <br /> Z,7 0.,) <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 welland notify them before putting the. well in use. The above <br /> information is true to he es f my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T0,,_ OU ING AND AL SPECTION. <br /> SIGNED _4f7TITLE <br /> U (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G\cJZ - - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION ' <br /> INSPECTION BY DATE � /Zod:- INSPECTION BY DATE 74V <br /> E H 1426 Rev. 1-74 <br /> ' 1177 _ ZM <br />