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C� ,�,,�/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICV USE: ��"�� "" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ., Telephone: (209).. 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� �7P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -6-'J <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct F <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rulesand Regulations of thq San Joaquin Local Health District. <br /> JOB -ADDRESS/LOCATION A*e.r14 O 1e � � f�;Q CENSUS TRACT <br /> Owner's Name cAoy�-L, / �� Phone ' <br /> 0 9ft <br /> Address Q 0 yG G City �T <br /> Contractor's Name CSA License #/f <br /> i>w'Phone <br /> or <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <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 J <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 Y Surface Seal Installed By,: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP *10ft{g; State Work Done 6el4, e-,,10 �a /��•y,r� <br /> DESTRUCTION 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, I will 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 to the best of- my knowledge and belief, I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GRO •TING AND A FINAL INS .' Q <br /> SIGNED ITLE <br /> - PLO PAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR SPECTION PHASE III FINAL INSPECTION - <br /> INSPECTION BY V DATE INSPECTION BY DATE <br /> a f77 2rr3 <br /> E H 1426 Rev. 1-74 r <br />