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SAN.JOAQUIN- LOCAL HEALTH DISTRICT <br /> 0R.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 446-6781 , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' S- _-14 <br /> 7� <br /> ._ <br /> (Complete In: Triplicate) <br /> iApplication is hereby made' to the San Joaquin Local Health District for a permit to consitruct <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 (e>3Q 213 11 -CENSUS TRACT <br /> Owner's NameJG APhoned "a <br /> Address _ <br /> . . - City ' <br /> a <br /> Contractor's Name , N � _ License #Q <br /> __�Z) Phone '' <br /> TYPE .OF WORK (Check): NEW WELL/7 DEEPEN.'/? RECONDITIONf7 DESTRUCTION / f <br /> PUMP :INSTALLATION / / PUMP REPAIR/� PUMp 'REPLACEMENT <br /> Other <br /> -DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPIT OTHER <br /> PROPERTY LINE .-�f_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, Informationt <br /> Geophysical ¢• w Surface .Seal Inst -1161 'B <br /> PUMP INSTALLATION: --Gontractor <br /> Type of H.P. I <br /> PUMP REPLACEMENT: State Work Don <br /> PUMP ,.REPAIR-.REPAIR ... 17 State Work Don _ — <br /> DESTRUCTION OF WELL: . Well Diameter ' <br /> Approximate Depth <br /> Describe Material and Procedure # <br /> I hereby agree't,comply faith 411-laws;and regulations of the San Joaquin4Local 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 R]PQRT-raf�the�well'`s td"notify them before putting the .,sell. 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 EYALTING A FINAL INSPECTION. 1 <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i � <br /> APPLICATION.ACCEPTED :BY '} DATE rf=�� -71 <br /> ADDITIONAL COMMENTS. � - <br /> PRASE II GROUT INSPECTION PHAS II INAL INSPECTIO f <br /> (INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 rr .: h/75 2M J, <br />