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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0R' OF US$: 1601 E. Hazelton.Ave: , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> l APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -74f�r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1--1Y-,7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local. Health District f.or "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 . S o� �_ Cain' CENSUS TRACT / <br /> Owner's Name fo 4 p � �j � Phone <br /> Address C7 .• � a�/r�r nih� City SV/Ve4l"!� F <br /> V. <br /> Contractor's Name , _) wLicense # /,f,4 Pad— Ione �•-�� �+ <br /> Y <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN' /�/ ,RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /X/ PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITT PRIVY a <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 yk 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 /> Cathodic Protection Rotary Type of Grout" . . <br /> Disposal Other Other information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: - Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done E <br /> PUMP .REPAIR: j/ State Work Done �]rc✓O' iri <br /> DESTRUCTION OF WELL:' : Well Diameter Approximate Depth <br /> Describe Material and Procedure r <br /> I hereby agree to comply with all..laxbs and regulations of the San Joaquin Local. Health Districtf <br /> and the State of California pertaining tokor regulating well "construction. Within FIFTEEN DAYS <br /> after completion of " work on a new well, I will furnish the San Joaquin Local Health Districts <br /> WELL DRILLERS REPORT of the Well and notify them before putting thewell in use.. . The above <br /> information is true to the best--of. my kn wle e nd 'I, of. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR NG AMID A FINAL I PECTION. <br /> SIGNED Fe,0 ,X TLE + ° <br /> .(DRATI,LO AN ON REV SE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE T # <br /> APPLICATION ACCEPTED BY +, DATE 1 <br /> ADDITIONAL COMMENTS: <br /> ' PHASE II GROUT INSPECTION. P iII,/FINAL INSPECTION <br /> INSPECTION BY' ` - DATE INSPECTION B DATE <br /> f <br /> E H .1426 Rev. - i-74 <br /> of 77 _ 2M <br />