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SAN JOAQUIN LOCAL HEALTH DISTRICT �•. <br /> FOE OFFI SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D <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 _26 7` - « /� g •� .CENSUS TRACT - - <br /> Owner's NameC27� A_e? _ Phone w <br /> Address � � <br /> City <br /> - <br /> r <br /> Contractor's Namee4- License oneg �� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION f_1 DESTRUCTION /_7 <br /> PUMP INSTAL ATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK FLO 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 71 <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection E3 Rotary Type of Grout zo <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Jv- <br /> PUMP INSTALLATION: Contractor J3 4 9.,p444 in <br /> Type of Pump /IU _7 W ITI V? !E;7 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 'constructi.on. 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 <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEr <br /> FOR EPARTMENT USE ONLY <br /> PHASE I tl <br /> APPLICATION ACCEPTED BYK�L� DATE ! Q <br /> ADDITIONAL COMMENTS-. �,GvwCa <br /> PHASX JI M617r INSPECTION P 5 I/FINAL NSPECTION <br /> INSPECTION Bf DATE •-.— INSPECTION BY ,cam - DATE <br /> E H 1426 Rev. . 1-74- f <br />