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f <br /> G[0Iyr_ `Bd �/1601 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> p ,FOE CE USE: E. Hazelton Ave. , Stockton, Calif. <br /> A � 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 Distract for a permit to construct <br /> and/or install the work herein 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 / -47 CENSUS TRACT <br /> Owner's Name `�ja a o - Phone <br /> Address 4 7 �d rm t..r City <br /> �f Contractor's Name �-l t,� License # y one <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /T—I RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLATION/ / PUMP REPAIR REPLACEMENT 1-7 <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 <br /> JC 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 x Other Other Information <br /> Geophysical Surface Seal Installed-By: <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: . / / State Work Done <br /> k PUMP .REPAIR: / / State Work Done .�- r r, 4- <br /> r 7 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f '\ <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. know e e U be f. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G I .G AND A F NAL INSPE <br /> SIGNED <br /> (DRAW f B I PLAN 'ON RE SE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I A APPLICATION ACCEPTED BY DATE Q <br /> 4 <br /> ADDITIONAL COMMENTS: <br /> PHASE I-I GROUT INOSCTION PHA INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY ILI' . DATE <br /> .- - <br /> E H 1426 Rev. 1-74 f 3/76 2M , <br /> - ter• ---- <br />