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SAN JOAQUIN LOCAL HEALTH DISTRIC' <br /> k FOE'OFFTCE" USE: 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, <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 Vith San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San "Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 3CL 5. CARiCOG .0A1 0 CENSUS TRACT <br /> Owner's Name SIVA L 4: Phone � <br /> Q <br /> Address ;�MKO L 6 . <br /> City <br /> Contractor's Namen <br /> rk ��"� �Z�C License #20Q-7 Phone f <br /> TYPE OF WORK (Check) : NEW WELL //V DEEPEN "/% RECONDITION F7DESTRUCTION /7 k <br /> PUMP INSTALLATION KI, PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /_7 <br /> y e <br /> DISTANCE TO NEAREST: SEPTIC TANK aQof SEWER LINES ZOO" 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 Z� <br /> Domestic/private Drilled Dia. of We11. Casing �� <br /> C Irrigation Driven-Driven_ d-, r— ,._Gauge-of._Casing <br /> ��_ Irri anon <br /> g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> 3 <br /> Geophysical Surface Seal Installed B C - <br /> PbMP INSTALLATION: Contractor <br /> -Type of Pump H.P. Q <br /> PUMP REPLACEMENT: / / State Work Done # <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t � <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District F <br /> and-' he State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS f <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 'qELL 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 NG AND A F2VAL 1N8PFrTT0N, <br /> SIGNED TITLES <br /> D W PL T PLAN :ON REVERSE SIDE <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -a'��1`�y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY il�� DATE INSPECTION BY DATE -3/ -7? <br /> 4 <br /> E H 1426 Rev. 1-74 � n� � �� 3/76 2N <br />