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f ro v�•- L r� � � SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOE76 CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <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 stealth 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 /> JOB ADDRESS/LOCATION CS �- _ CENSUS TRACT t <br /> Owner's Name Phone <br /> Address , t? City ` <br /> Contractora Name �... License # 'Phone o6X_= ,?7 <br /> 4 TYPE OF WORK (Check) : NEW WELL/? DEEPEN '/ RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT �• <br /> Other /_7 p <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 /> Domestic/private. ' =' Drilled --Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> r Cathodic Protection Rotary Type of Grout <br /> # Disposal Other Other Information <br /> Geophysical 'Surface Seal Installed By: <br /> PUMA' INSTALLATION: Contractor � 1e Z, <br /> Type of Pump H.P. _G U <br /> PUMP REPLACEMENT: State Work Done ,, Z62— 04 10ALA <br /> s <br /> 3 . . <br /> PUMP 'REPAIR: /_" State'Work Done -- - <br /> ES TRUCTION 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, Ilwill 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 ta, the-best of myowled a and-b lief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING-AND A FINAL INSPECT 0m <br /> SIGNED TLE <br /> (DF4W PALO .PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ¢M <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE G <br /> 't <br /> -74 2M <br /> '~E H 1426 Rev. 1-74 _ 3 ,._{ <br />