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SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton,-�Calif. <br /> Telephone: (209) 466-6781 -�� �'L � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> N. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuLd � <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe San Joaquin Local Health District for A permit to construct <br /> and/or install the work herein described. This application is mad in compliance with San Joaquin <br /> County Ordinance No. 1862 and1the Rules an R ulatie�s of�theS Joaquin Local Health District. <br /> '6) ENSUS TRACT <br /> JOB ADDRESS/ OCATION / `~ <br /> Phone 4k� <br /> Owner's Na <br /> � <br /> Address 1161 + City�y� e" 1 !� <br /> t LicenseA44�3 3Phon ,"/ <br /> Contractor's Name <br /> E i <br /> TYPE OF WORK (Check) : NEW WELL f / DEEPEN / / RECONDITION /-7 DESTRUCTION /=T <br /> PUMP INSTALLATION/ / PUMP REPAIR/ UMP REPLACEMENT 1-7 <br /> Other 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY \i <br />€ SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE -» PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> E Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public i_ _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., i Surface Seal.. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump, r ti H.P. <br /> PUMP REPLACEMENT: . / / State Work Done es' <br /> ,PUMP REPAIR: ' /✓/� State Wo - <br /> - <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 an 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 /> f 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 GRO TING AND A FINAL INSPECTION. , <br /> SIGNED _ON REVERSE TITLE <br /> DRAW'P T PLANSIDE) r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 5 APPLICATION ACCEPTED BY J DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '�" <br /> _ 3/76 214 <br /> E H 1426 Rev. 1--74 _. <br />