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' / SAN JOAQUIN LOCAL HEALTH DISTRICT ( <br /> FOR OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - _7-_74 <br /> (Complete In Triplicate) <br /> Application is hereby made to the ,,an 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 Regul tion of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI <br /> QN <br /> CENSUS TRACT <br /> Owner's Name Phone '?cy! <br /> Address City <br /> k. <br />. Contractor's Name y �.�` License lta: J hone � <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 TANK l SEWER LINES PIT PRIVY T <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 /> F/Domestic./private Drilled Dia, of Well Casing - ' <br /> Domestic/public Driven Gauge of Casing 12.0 <br /> Irrigation Gravel Pack _ Depth of Grout Seal <br /> Cathodic Protection �fRotary Type of Grout _z <br /> &j,r1 �! <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> + f <br /> PUMP INSTALLATION: Contractor 1 <br /> 'Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING D A,° IN INSPECTION. <br /> SIGNED.. TITLE <br /> (DRAW 'Z T PLAN 'ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: w <br /> PHA6V II G OUT INSPECTN _ PHAS•°..-_--- <br /> ••• • E I /FIN INSPECTION <br /> INSPECTION BYDATE INSPECTION BY., DATE <br /> / 1 rry et <br /> E _H .1426 Rev. 1-74 Wj,, 3 _24 <br />