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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;?,7- 3 - <br /> THIS PERMIT EXPIRES' l .YEAR FROM DATE ISSUED. Date Issued <br /> (�O (Complete. In Triplicate) <br /> Application is heremade 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 3. rX rv! j CENSUS TRACT <br /> Owner's Name { y 19 <br /> Phone 5 r} <br /> j Address ---�3 5- 7 -5, W ys city - <br /> Contractor's Name ,I ( E+S License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / f RECONDITION /_/ DESTRUCTION /7 4 <br /> PUMP INSTALLATION f��PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other /77 <br /> DISTANCE TO NEAREST: SEPTIC TANK $(j SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIqCA��ONS <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFI <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing j <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 B <br /> PUMP INSTALLATION: Contractor Na dp !/- <br /> Type of Pump zu r' H.P. -Id <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> !/ Gam, <br /> DESTRUCTION OF WELL: We�Daameter G � j ���� / Approximate Depth <br /> k 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 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 G AND 6F F,17AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY rDAT -1 '7 <br /> ADDITIONAL COMMENTS eA'`� <br /> PHASE I GROUT INSPECTION "� _ PHASE ILII/FINAL INSPECTION <br /> INSPECTION BY DATE .INSPECTION BY. ; _ .• /„ �F iDATE f,-���7 <br /> - bf77�2M <br /> E H 1426 .._ ..Rev. , 1-74 <br />