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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OF CE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7'- Q/ <br /> �• ,o rCsl teo-r-, THIS PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued Ea��7 <br /> 0 � (Complete In Triplicate) <br /> Application iby 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 G;4 F3 x A &e- <br /> CENSUS TRACT <br /> Owner's Name /3 � �[�r/1• Phone <br /> Address Al /10 City <br /> Contractor's Name <br /> License # ?X j'`Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_% RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /_ <br /> Other <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 <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 <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractort'� <br /> Type of Pump ee r` i�aF -�= H.P. s <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /h/ State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter N <br /> Describe Material and Procedure Approximate Depth <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 wledge '__b__0,1ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INS <br /> SIGNED TLE ' <br /> ( RAW T P AN ON RE SE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ] �J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - HASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> E H 1426 Rev. - I-74 �w / n��%7 d 2M <br />