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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton,' Calif. ' � . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,7-6_5-e)6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZAL7 <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 W7 A/ AnA zot, CENSUS TRACT <br /> Owner's. Name a d4t Phone E <br /> Address City <br /> Contractor's Name _ �.�� License # LPhone 1 -76�( <br /> . 1 <br /> tl <br /> TYPE OF WORK (Check) : NEW WELL '/_/ DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR 'Ae/_ PUMP REPLACEMENT /_7 -' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r-1 <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/pub lic- . _ u- _ Driven:. .Gauge*of Casing mil <br /> �y Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information {' <br /> GeophysicalSurface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor �s r.._ <br /> Type of Pump `> H.P. <br /> PUMP REPLACEMENT / / State Work Done l <br /> PUMP .REPAIR; i <br /> 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 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 knowled an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UT G AND FINAL CTIO <br /> SIGNED . TLE <br /> (D PLO P ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br />. APPLICATION ACCEPTED BY "� DATE J <br />. ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE II1jfINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1177 ` ` M <br /> L--- - - ------- <br />