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ld� SAN JOAQUIN LOCAL HEALTH DISTRICT r r/ <br /> FOR OFPICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. rl~ <br /> Telephone: - (209)' 466-'6781 <br /> APPLICATION FOR WELL CONSTRTJCTIONOR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1-YEAR FROM.DATE ISSUED Date Issued /A/]�-77 <br /> ' (Complete In -Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health,Distriet 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 /> � / C wDrTvw <br /> JOB ADDRESS/,LOCATION 6W/&?2✓ I? CENSUS TRACT <br /> Owner's Name 0 0 M Phone <br /> AddressCy G oo � .�.y 6 Cit <br /> Contractor's Name � '� a��. License #/t3_2?,JPhone , <br /> F i <br /> i <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /" / DESTRUCTION /_ <br /> PUMP INSTALLATION /�/ PUMP REPAIR /X/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . , PIT PRIVY s <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -T"4c ►�° H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: — .._..-..`._ ..--_.__. <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and -Procedure <br /> r <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 h.em before putting the well in use. The above <br /> information is true to the bes my n ledge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO gTING AND A FINA C <br /> SIGNS ITLE <br /> (DRA LO PLAN ON. FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION �. PqAV j1 <br /> /F NAL INSPECTIO, <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> E H 1426 Rev. - I-74 2M , <br />