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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: E.E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL'CONSTRUCTION OR PUMP PERMIT Permit No. -A � <br /> ' 77�S��p <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 Regulations of the San Joaquin Local Health District. ? <br /> CENSUS TRACT E <br /> JOB ADDRESS/LOCATION <br /> r6G�-- _ ". <br /> Owner s Name Phone <br /> �� i - <br /> Address <br /> I� City € <br /> Contractor's Name A4 lot) <br /> t License hone <br /> TYPE OF WORK (Check).: NEW WELL ' DEEPEN/ J RECONDITION / / DESTRUCTION /-7PUMP INSTLATION I PUMP REPAIR / / PU1+�P REPLACEMENT 1-T <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK 5LO -. SEWER LINES 4-PIT PRIVY t <br /> SEWAGE DISPOS# IELD CESSPOOL/SEEPAGE PIT �AtOTHER (A ; <br /> I` PROPERTY LINE<-� RIVATE DOMESTIC WELI/� UBLIC DOMESTIC WELL <br /> { , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f� { <br /> Industrial .{ Cable Tool Dia. of Well Excavation <br /> � ( Domestic/private Drilled Dia. of Well Casing <br /> � _ <br /> Domestic/public !. Driven Gauge of Casing <br /> Ti- Gravel Pack Depth of Grout Seal � . <br /> Irrigation <br /> Cathodic Protection Rotary Type of -Grout 1� <br /> Disposal ! Other Other-;:Information _. <br /> Geophysical Siarface Seal Installed B <br /> � �h �`' <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump d �j <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 'State Work Done ' <br /> .-Diameter Approximate Depth <br /> DESTRUCTION OF WELL: Well'° <br /> DescAbe--Material- and Procedure <br /> I hereby agree to comply with all laws and regulations off the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating wel.l'construction. Within FIFTEEN DAYS <br /> after completion of my work4on 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 /> i information is true to the best of- my -knowledge and4belief. ►,I WILL- CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECT TITLE <br /> SIGNED »=_- - <br /> W L LAN"ON RE FRSE SID <br /> • FO DEPARTMENT USE ONLY <br /> PHASE I DATE,� <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: r PHASE I/FINAL INSPECTION <br /> ``�` PHASE II GROUT- INSPECTION Y _ TE <br /> INSPECTION BY I/rL_ _ DATE. INSPECTION BY <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 — - <br />