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t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.OFFiCE U5Es 1601 E. Hazelton Ave., Stockton, Calif-. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - <br /> 7e,-,;?74° !° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATH ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local 11calth District for a permit to construct <br /> and/or a.netall, the work hereii a cation is made in compliance with San Joaquin <br /> County Ordindnce No. lE fid th�73 <br /> an egule on o the San Joaquin Laval Health District. <br /> r�J �'1 �� <br /> JOB �S/LOCATIOrTit`�S 1W 7tf,f2 t" , CENSUS TRACT <br /> Owner's Name �i /r Phone <br /> Address City <br /> i <br /> Contractar'b Name �lL�l�Yl�1l�/?� �GJY <ll1Ts License. 9,6 -•fy Phoae <br /> TYPE OF WORK (Check): NEW WELL /V DEEPEN '/7 RECONDITION /_J DESTRUCTION 1`j <br /> t PUMP INST ;CATION 4V PUMP REPAIR /7] PUMP REPLACEMENT f7 <br /> Other L/ <br /> DISTANCE TO NEAREST: SEPTIC TANK _3�. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE GE PIT, OTHER <br /> - r'— \ <br /> PROPERT7 LINE-PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL7:M <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> __4X_L Industrial X Cable Tool Dia. of Well Excavation / 'Z— <br /> Domestic/private <br /> ZDomestic/private Drilled Dia. of Well Casing v <br /> Domestic/public Driven Gauge of Casing 7 tc <br /> -Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surfaze Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. y <br /> PUMP REPLACEMENT: / / State Work' Done <br /> PUMP •.REPAIR: / / State Work. Done <br /> DES•T�RUCTION Or 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 II?YS <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 true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR, TO :.•ROUTING AND A 'FINAL INSPECTIO ' <br /> S IGN- - � <br /> 11- -- <br /> W PLOT P ON REVERSE SIDE <br /> FOR D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/ DATE —Z <br /> ADDITIONAL COMMENTS: <br /> zl- <br /> PHASE II G _N ECT PHASE III FINAL INSPECT N <br /> INSPECTION BY / c " f DATE INSPECTION BYHATE ZV <br /> E H 1426 Rev. 1-74 1/75 2M <br />