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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FO-Fl-''OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--67$1. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,27 r,;O?P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued6-,d,7,��, <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 i <br /> County Ordinance No. 1862 and the Rut s and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i <br /> Owner's Name Phone <br /> Address 3a7 City <br /> 4f-lztx <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_/ DESTRUCTION -/_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <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 y Cable Tool Dia, of Well Excavation <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 r Surface Seal. Installed BY: <br /> PUMP INSTALLATION: Contracto adld� <br /> Type of Pump .P. <br /> PUMP REPLACEMENT: / / State Work Done G ` <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'-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 th best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TING NAL INSPE.,CTIOM <br /> SIGNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G✓ DATE -72 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATEX� //4- INSPECTION BY ATE -2 3-77 <br /> . 11Z7 • 2M <br /> E ,H 1426 Rev. 1-74 'ry <br /> _ <br />