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G� A0A0 &JOAQUIN LOCAL HEALTH DISTRICT t I <br /> FOR CEFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.', 21d <br /> I • i 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7d <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 San-J6aquin <br /> County Ordinance No. 1862 and the Rules and Regulations of> the Sari Joaquin Local Health District,. <br /> JOB ADDRESS/LOCATION C/4:;_r CENSUS TRACT <br /> Owner's Name {Lr o +�1 ; x ) / Phone <br /> '��+�M �'�/ � <br /> Address G City. <br /> Contractor's Name <br /> License # _ja ;?vf"'Fhone 1` 7 <br /> 'TYPE OF WORK (Check) : NEW WELL /? DEEPEN /_7 RECONDITION /? DESTRUCTION, /7 <br /> PUMP!"INSTALLATION/ PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT11ER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE .OF WELL CONSTRUCTION SPECIFICATIONS . ' <br /> IndustrialCable Tool. Dia. of Well. Excavation <br /> �X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Pr Driven Gauge of Casing <br /> Irrigation i, Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> ' Geophysical u' . Surface Seal Installed BX: <br /> PUMP INSTALLATION: Contractor a.c. <br /> Type' of Pump <br /> H.P. <br /> ;. ✓ <br /> PUMP REPLACEMENT: / / , State Work Done <br /> PUMP .REPAIR: Ll " State Work Done <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 FITTERN 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 ab+ ve' <br /> information is true to the-best of kno edge belief.. I WILL CALL FOR A GROUT I�SPECTI(3i�I.` <br /> PRIOR TO NG AND A FIN LEC_ T 1 <br /> SIGNEDTLE <br /> Ix D W P ON SE SIDE 1 <br /> FO ARTMEN USE ONLY <br /> Ir PHASE I <br /> APPLICATION ACCEPTED d D ¢� DATE <br /> ADDITIONAL I:ONMENTS: <br /> PHASE If GROUT INSPECTION PHAS III/MAL INSPECTIO <br />` INSPECTION BY DATE INSPECTION BY DATE Z <br /> _ r'. _� V76 21 <br /> `E S 1426 Rev. -i-74- <br />