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s II -- <br /> SAN JOAQUIN LOCAL HEALTH <br /> FOE.OFFICE� USE: 1601 E. Hazelton Ave. { <br /> Stockton, -Cali£. <br /> Telephone: (209) 466-6781 <br />€ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED7b <br /> .Date Ieaued- ��d <br /> Applicati (Complete In. Triplicate) <br /> on is hereby meda to the San Joaquin Local Health District for a permit to construct <br /> and/or install the workpherein 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 I ji 17 <br /> CENSUS TRACT <br /> Owner's Name , <br /> ;p Phone ' <br /> Address <br /> . n �M City <br /> Contractor's Name (�-Ss <br /> .I� License43�l��Phone-7�-S'�- <br /> TYPE OF WORK (Check): NEW WELL DEEPEN <br /> — RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION f PUMP REPAIR/7 PUMP REPLACEMENT <br /> Other /7-/. <br /> - _ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - .PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WELL <br /> INTOTHER <br /> ENDED USL TYPE OF WELL CONSTRUCTION SPECIFICATIONS \j1 <br /> Industrial � Cable Tool <br /> I Dia. of Well Excavation /�Z <br /> Domestic/private Drilled - Dia. of Well Casing <br />_ Domestic/public +' Driven \� <br /> Irrigation . "`" Gauge of Casing <br /> r� :- . Gravel Pack Depth of Grout Seal <br /> Cathodic Protectio_ n Rotary ! <br /> - Disposal _ �-'` � Type of Grout <br /> 1 Other Geophysical Other Information <br /> . _ I� ��•- <br /> Surface Seal Installed B i <br /> PUMP INSTALLATION:. Catractorlow <br /> . z,6 s7G <br /> &.,,..._ Type .of PumpPUIMP <br /> REPLACEMENT; / •State Work" 'ne-- <br /> a <br /> k D <br /> ne g `� <br /> `.REPAIR: / -.Stag ,Work Done <br /> DESTRUCTION OF WELL: ^� Well Diameter <br /> Describe Material and <br /> Procedure Approximate Depth <br /> II <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 /> Lnformation is true to the•best .of.my..knowledge and belief. I WILL CALL 'FOR 'A 'GROUT INSPECTION <br />'RIOR TO GROUTING ANDL A NAL INSPECTION. <br />"SIGNED ,F <br /> k DTITLE <br /> LOT ON REVERSE SID <br />'RASE I FOR DEPARTMENT USE ONLY <br /> YPLICATION ACCEPTED BY <br />►DDITIONAL COMMENTS: DATE ' 7 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECT 0 <br /> INSPECTION BY �€ DATE �_z y 7 ` <br /> =--=—_7 ._INSPECTION BY �� DATE 7 x <br /> E a 1k26 Rev. 1-74 i .Yt <br />