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4 <br /> C8W7/I) SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> FOF..OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermitNo. �_ <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. Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with Sen Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.,, <br /> JOB ADDRESS/LOCATION /od A---u -e, CENSUS TRACT ` <br /> Owner's Name ya�C Phone ' <br /> Address ch0 ✓� �-ri _ City <br /> Contractor's Name° �� License # G ?�Phone <br /> s4:2- -7G <br /> r w <br /> F.K <br /> TYPE OF WORK (Check): NEW WELL -/? DEEPEN '/7 RECONDITION f7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / '/ PUMP REPAIR -/� PUMP REPLACEMENT /7 <br /> Other C7 <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 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 /> f Industrial Q <br /> Cable Tool Dia. of Well Excavation <br /> � <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 /> i Disposal : Other Other Information <br /> Geophysical. Surface .Sea1.,Ih9t9lled By <br /> PUMP INSTALLATION. Contractor` t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /KI State.Work Done _ zz <br /> I PUMP .REPAIR: /-7 State Work Done <br /> ' DESTRUCTION OF .WELL: Well Diameter Approximate Depth <br /> i 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 .wel'l. 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 GROUTING AND A FINAL INSP N. <br /> SIGNED J cif �.,_f ITLE De e, <br /> f D P PLAN ON E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - i <br /> APPLICATION ACCEPTED BY .DATE ' <br /> ADDITIONAL COMMENTS: a "' <br /> L <br /> PHASE II GROUT INSP CTION PHASE II .FINAL INSPEC O <br /> INSPECTION BY DATE -BY DATE fr <br /> ,; E H 1426 Rev. 1-74 r 1170 om <br />