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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT zoo 0.6 <br /> �V <br /> FORy,QFF CE USE: 1601 E. Hazelton- Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4Z-1S-7 7 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q. < '/ S, 60A.4LtjQ14fmn _P[ch«CENSUS TRACT <br /> Owner's Name / Phone <br /> Address, L' -T;7cGrt �4 y, GCS a City �7a;rn 0 <br /> Contractor's Name License # Phone C/ y fa <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 y� <br /> Domestic/private Drilled Dia, of Well Casing `-*P0 <br /> Domestic/public Driven Gauge of. Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Gontractot <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> __... #AV <br /> PUMP REPAIR: / State Work Done j PWf <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth (n <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 knowled4e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL NSP ON <br /> SIGNED ,/TITLE <br /> (DRAW PLOT PLAN ON-MZVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /- DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY DATE l�. --,14-, j7 <br /> c r <br /> E H 1426 Rev. 1-74 ' 1177 2M <br />