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C' SAN JOA UIN .LOCAL HEALTH DISTRICT ,�'�,, i <br /> FOR 0 ICE USE: 1601 E. Hazelton Ave:-, Stockton, Calif. -u=�� "� n= <br /> Telephone: (209) 466- 6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR'PUMP PERMIT'Y' �I�17, Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED (JDate ISSURC 28 1077 <br /> (Complete In Triplicate) <br /> Application is hereby made t- 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 Joa yin Local Health District. <br /> JOB ADDRESS/LOCATION oc., t/ - s�' A S ���6.+ CENSUS TRACT <br /> r <br /> Owner's Name �e n k_ Phone <br /> Address SIG• City <br /> Contractor's Name - ? License #/ y Phone W <br /> -M <br /> TYPE OF WORK (Check) : NEW. WELL / / DEEPEN. / / PRECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION ,/,f PUMP REPAIR PUMP REPLACEMENT / f <br /> Other u / . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEtDISPOSAL 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 /> 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 1 Other Other Information \ <br /> Geophysical Surface Seal Installed By : -_ <br /> ti <br /> PUMP INSTALLATION: Contractot <br /> Type of "Pump H.P9! <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: I AQ P- <br /> X Work Done, rf <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 Distract <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 bes my n`wled-ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOTING ;ED, FIN SP C <br /> SIGNE _ TITLE <br /> (DRAV PLOT PLAN OWREVERSE SIDE) <br /> FO EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BX DATE <br /> ADDITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHAS ITT/FINAL INSPECTION <br /> INSPECTION BY : DATE INSPECTION BY ATE <br /> 2M <br /> E H 1426 Rev. - I-74 <br />