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e SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOR OFFIC USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. $ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> w (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 <br /> CENSUS TRACT <br /> Owner's Name go 1'l-A G[J 9`7 <br /> Phone <br /> Address- ! l 6 G� stn City <br /> License # Phone '41-74 <br />. Contractor's Name . <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN/ / RECONDITION lT DESTRUCTION /7 <br /> PUMP INSTALLATION J PUMP REPAIR/ I PUMP REPLACEMENT I? r� <br /> Other <br /> 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 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well- Excavation' <br /> ; <br /> -�, Domestic/private Drilled Dia: of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel .Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ; <br /> Disposal . Other Other Information <br /> --Geophysical Surface Seal Installed By: <br /> 71 <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump . a f H.P. ' I <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP . V: State Work Done 0a Al <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material. and Procedure <br /> I hereby agree to comply with all lawsand 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 tnew. 'wel1, I'.^uFill 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 /> I� information is true to the best°oaf my--knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND. A FINAI- INSPEC -1O <br /> SIGNED . . TEf <br /> ` hSRA T PhAN ON RE RSELE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II G. QUA IN ACTION PHASE III/FINAL INSPECTION <br /> -77 <br /> INSPECTION BY `DATE INSPECTION BY DATE <br /> - 3/76 2M. <br /> E H 1426 Rev. 1-74 - ' <br />