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r <br /> _ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR DVFICE..USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _.ice Op <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 egulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name dq M/fc, . yc'41 Phone f5T'��d <br /> Address O _ Ct.r� Q �,c�C.Cp City <br /> Contractor's Name dJ License Y <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN.,-/ / RECONDITION 17 DESTRUCTION /7 <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 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 - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor d <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / ,/ State Work Done <br /> PUMP .RE / / State Work Done <br /> DE •TRUCTION OF WELL: Well Diameter _ � _ Approximate Depth <br /> Describe Material and Proced A <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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL IN PE ION. <br /> SIGNED TITLE <br /> DRAW PLM <br /> PLANON RE FRSE SIDE) + " <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r4 DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE �7J <br /> (J`�sr ���✓�� <br /> E H 1426 Rev. 1--74 3/75 2M <br />