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Cq I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ;4 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7G- Zl g /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (�� <br /> (Complete In Triplicate) ' <br /> Application is hereby made -to the Sari 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 a�. � LL l ' - CENSUS TRACT <br /> Owner' I s Name (`C� 1�p Phone <br /> Address <br /> ri( City . . ,rm-, 4LA, <br /> Contractor's Name ~" .c3 License # /f3 77-j "Phone s <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR y-7 PUMP REPLACEMENT /7 <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 Cn <br /> Industrial Cable Tool Dia. of Well Excavation <br /> --- 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 Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ever, <br /> Type of Pump ,. H.P. x— <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: I}C State Work Done Ida -i A" ilo-ol.1 <br /> 4 <br /> ,SES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all •laws 'and regulations of the Sar: 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 puttingthe- well in.use.. The above <br /> information is true to the best of- my knowledge and be ef.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO Gr AND A FINAL INSPECTION <br /> SIGNEDTL - n►�' <br /> DRAW PLO LAN ON REVERSE SIDE) <br /> R ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT Y &M�Ze�>IAF �(J UI✓ DATE <br /> ADDITIONAL COMMENTS:. <br /> PHASE II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1712`?C <br /> 3 „E H 1426 Rev. 1-74 1_7A ?M <br />