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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOF,:O ICE USE: v 1601 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 /> 4 (Complete In Triplicate) <br /> Application is hereby made to the Son 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 Joaqui <br /> :County Ordinance No. 1862 and the Rules and- Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / 6 Wit) CENSUS TRACT . <br /> Owner's Name gyp,ir7. -� ckos n Phone ' <br /> Address . ( city . rJ� <br /> Contractor's Name G/ ac..-r License # ' P °Z� <br /> hone <br /> Y_ t <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN/7 RECONDITION f7 DESTRUCTION /7 <br /> PUMP INSTALLATION`/ / ' PUMP REPAIR 27 PUMP REPLACEMENT <br /> Other /_7 <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 /> t - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> tRotary Cathodic Protecion <br /> � _. Y T ype of Grout <br /> Disposal Other Other Information <br /> Geophysical• .Surface Seal Iiistalled By: <br /> PUMP INSTALLATION: Contractor <br /> _..Type,of-Pump _ � � z- ` �, H.P. 1� <br /> PUMP REPLACEMENT: . / / State Work Done` <br /> PUMP ,.REPAIR: / / :State Work Done; <br /> DESTRUCTION OF WELL: Well Diameter k # 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'constructi:on. 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 /> f information is true to the�best .of my.-knowledge and ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT NG AND A FINAL INSPECTIO <br /> SIGNED I T L E <br /> (DILW KQT PLAN ON REVERSE SIDE <br /> F D PARTMENT USE ONLY <br /> iRHASE I17 <br /> `. <br /> APPLICATION ACCEPTED BY DATE ,7� <br /> ADDITIONAL COMMENTS: 4Z 4 <br /> PHASE Il G O SECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - -� <br /> r _ E H 1426 Rev. '1-74 h/79 2M <br />