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A war <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT to <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. rs c Vir 40,, <br /> 1: e, <br /> _. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <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 inst.all. the: work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 118622 axid .the Rules and Regulations of .-the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. Q G"V CENSUS TRACT ' <br /> Owner's Name Phone <br /> Address d, j City <br /> Contractor's Name "� /I%� ��(,�,.. License 17ZIPI J� Phong3 -5 �5 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/% RECONDITION / / DESTRUCTION /-7 <br /> PUMP 'INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> OtherF / / <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 SPECIFI <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ] <br /> Domestic/public t Driven Gauge of Casing �.. <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection t Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor { <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / iState Work Done <br /> PUMP REPAIR: / / State Work Donep <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 se. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING,AND FINAL INSPECTION. <br /> SIGNED f aTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` + Cn DATE ' \77 ' <br /> ADDITIONAL COMMENTS: 4 <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 6-pz� DATE ,;; ?f <br /> E H 1426 Rev. � 1-74 4 �L ,._� b/77 <br />