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Co SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0I _F SCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> s% APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l'YEAR FROM DATE ISSUED Date Issued J <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 a. ° ue L6 S 'AAjffda dy- to z w r CENSUS TRACT <br /> Owner's Name <br /> � Phone <br /> Address � E. L. ✓ City e� i <br /> Contractor's Name License # e U 2 hone 41j�y 7 <br /> TYPE OF WORK (Check): NEW WELL ,17 DEEPEN '/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /_1 PUMP REPAIR 2/ PUMP REPLACEMENT /-7 <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 Q <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> � <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 j <br /> Type of Pump H.P. /_ 0 <br /> PUMP REPLACEMENT: / / State Work Done N <br /> PUMP;:REPAIR: hc7 State Work Done ,� - q4 42 4 F <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION Y <br /> PRIOR TO TING ANDA FINAL INSPECTION, <br /> SIGNED ITLE - <br /> PRffPLOT ON RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> , PHASE I <br /> APPLICATION ACCEPTED BY DATE � _ b <br /> ADDITIONAL COMMENTS: <br /> PHASE IS GROUT INSPECTION PHASE IN INSPECTIO <br /> INSPECTION BY DATE INSPECTION- BY DATE u <br /> t <br /> co <br /> r `� E H 1426 Rev. 1-74 1-74 2M <br />