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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'.OFFICE USE: <br /> - - - 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /a <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. 1.862 and the Rules and Regulations of the San Joaquin, Local Health District. <br /> JOB ADDRESS/LOCATION 14 3 t S Ir EI,J �(, CENSUS TRACT <br /> Owner's Name Phone Q-` '� .., . <br /> Address <br /> - � � E Lor-sot City i <br /> I i <br /> Contractor's Name g l /? i8ex �, , License # Phone Ty s.- 3y ; <br /> TYPE 0FWORK (Check) : NSW WELL /7 DEEPEN '/? RECONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION /K/ PUMP REPAIR/� PUMP REPLACEMENT /7 <br /> f 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 />�x 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 cl <br /> Disposal Other Other Information' ' <br /> Geophysical Surface S <br /> . _ eat Installed By,. ,_ .,•.�._ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump rr- H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR., / Y State Work Done <br /> DESTRUCTION OF WELL: Weil Diameter Approximate Depth <br /> Describe Material, and Procedure ry <br /> I hereby agree to comply with all laws and regulations of the Sart Joaquin Local Health District <br /> And the State of California pertaining to or regulating mell *�construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 />'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ` L <br /> TITLE <br /> :!I (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ti ' <br /> APPLICATION ACCEPTED BY ��� r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II AL INSPECTI <br /> INSPECTION BY .11' DATE _ INSPECTIO14 BY DATE <br /> - ' <br /> E H 1426 ___ Rev. 1-74 p , r )j/75 -2M <br />