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`a o C ( SAN JO <br /> AQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6�-//je <br /> THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued <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 CENSUS TRACT <br /> Owner's Name w i r� �� <br /> Phone <br /> AddressS3 6 ;� <br /> IQ-r,� �I�oa W city <br /> Contractor's Name . I <br /> License #1 7 2tj"Mone-A 00 _` s�- 6 <br /> TYPE OF WORK (Check): NEW WELL /-T DEEPEN/? RECONDITION /T DESTRUCTION r7 <br /> PUMP INSTALLATION F7 PUMP REPAIR LW PUMP REPLACEMENT 17 <br /> Other E7 — <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. CN <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I <br /> Industrial Cable Tool Dia. of 'Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing 0\ <br /> Domestic/public Driven Gauge of Casing �l <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: State Work Done ` Ec <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-my.knowd :elie)4. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO I G ANDA IN INSPE <br /> SIGNED <br /> DRAW LO 0 REV4;;=I <br /> PHASE I FO -- <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEDBY 1 z DATE I -- , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2a <br />