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r I C <br /> k 6 /0-041ofnj SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFIC USE: t" A601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 workl� herein described. This application is.-made in compliance with San Joaquin <br /> County Ordinance No. 18,62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> j <br />{ JOB ADDRESS/LOCATION 414:�, �2•Trvcr CENSUS TRACT <br /> Owner's Name Phone <br /> Address ,. City <br /> Contractor's Name I� 4 <br /> I License �� one L " <br /> !, TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / /� RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> M they <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> P OPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS- <br /> Industrial Cable Tool ' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ )C Irrigation Gravel Pack Depth of Grout Seal <br /> tCathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By:__,_.. ..... rr - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f H.P. ®J <br /> PUMP REPLACEMENT: / / State Work Done <br /> ti <br /> PUMP REPAIR: hel State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1-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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND Al FINAL INSPECTI <br /> SIGNED M TYLE <br /> PhO PAN 'ON . SE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYE DATE 7 3 /;;;Z <br /> ADDITIONAL COMMENTS: I, <br /> PHASE II GROUT INSPECTION PHAS I/FI INSPECTI N <br /> INSPECTION BY jj DATE INSPECTION BY DATE Z <br /> i <br /> I —E-.H 1426 Rev. '1-74 3/76 2M <br />