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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFICJL SE 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �- -Z LTf <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. //�/S 71 <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 CENSUS TRACT <br /> Owner's Name / Phone <br /> Address - btu <br /> City � -- i.Mf. <br /> Contractor's Name License #93a&.YPhone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS EWER LINES �•� PIT PRIVY iL)e)zVe <br /> SEWAGE DISP ALttIELD _,17:j2i� CESSPOOL/SEEPAGE PIT e OTHER ' <br /> PROPERTY LIN IVATE DOMESTIC WELL/l-_ PUBLIC DOMESTIC WELL <br /> r <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well -Casing <br /> Domestic/public Driven Gauge of Casirig <br /> Gravel Pack Irrigation e. r <br /> Depth of Grout 'Seal r-p7 V -� �--- � <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information ,., <br /> Geophysical Surface Seal Installed B : <br /> - ' f <br /> PUMP INSTALLATION: Contractor <br /> Type . of Pump H.P. <br /> _ f <br /> PUMP REPLACEMENT: / / State Work Done _ - --- <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �� ��,�lJr�uc��_ Approximate Depth <br /> De cribe Material 4nd Procedure _ <br /> 0! ALL APs' _ / t. Jam; ; <br /> I hereby agree to co ly wzt ¢a l lawa reg� ns of" the SaoaTuin or 1 ith <br /> q Di§ <br /> and the State of California pertaining to or regulating we11 construction. Within FIFTEEN DAYS <br /> after 'cbmpletion 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 4ND.,4?FINAL INSPECTION. <br /> SIGNS o r TITLE <br /> —Ccr� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) T� <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY 1 <br /> , <br /> APPLICATION ACCEPTED By-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTIbN BYDATE S=- <br /> E H- 4426 - Rev. , 1-74 <br />