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i <br /> z4zM�}J✓ '�q_SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> FOR.OFFIC SE: 1601 E. Hagelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 11jQ <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 l _76 3 7 — .S, S 7,-Al CENSUS CT . <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name IP ^_7 Ark— License # � Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 .-- <br /> PUMP INSTALLATION/,4 PUMP REPAIR / / PUMP REPLACEMENT F7 <br /> Other <br /> Gi <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 N <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 Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPA / / State Work Done <br /> f/ 0 <br /> D S•TRUCTION OF WELL• Well Diametqk k L�d roximate Depth !� <br /> Describe Material and Procedure <br /> I here y 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 DAIS <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN A FINAL INSPECTION <br /> SIGNED TITLE <br /> �( W T P AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3 77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N PHA E FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1177 2M <br />