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f _ Q�� / SAN JOAQUIN LOCAL HEALTHj•DISTRICT A l0 <br /> -TO-F-,-OFFICE USE: /// 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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/LOCATIONS CENSUS TRACT <br /> Owner's Name G p . Q Phone -?Z-,3 F 4.2 <br /> Address cl S City 5714-1V <br /> jContractor's Name License #,9jp Phone �L/s' f�` "" <br /> ;i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITIO / / DESTRUCTION <br /> PUMP INSTALLATION '/ / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /QD SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE:.PIT OTHER A, <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL- <br /> INTENDED <br /> ELLINTENDED 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 O _ 1_9e <br /> ' <br /> Cathodic Protection Rotary Type of Grout <br /> ~ P Y w�-m- ..- �.--:. � �-` Surf-acenfori- Inst :- <br /> Disposal'"'`T""' - Other _� - Other-I <br /> ;'- Geo h sical-�------------,R - -�Seal� Installed By: <br /> PUMP INSTALLATION: Contractor + <br /> Type of Pump H.P. - - - <br /> i <br /> PUMP REPLACEMENT: F <br /> State Woik Done <br /> PUMP .REPAIR: State Work Done r' <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 we11, I wiff furnisF'the-Sari. '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 myknowledge and belief. I WILL CALL FOR A GROUT•r`INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. F <br /> SIGNED TITLE <br /> V!M*&W4t0T MA9 OR iffVKERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED $YDATE <br /> ADDITIONAL COMMENTS: , <br /> PRA5,E I PgOIJT INSPECT 0 <br /> P E II/FINAL INSPECTION <br /> INSPECTION YA DATE INSPECTION BY DATE11 Al <br /> O <br /> E H 1426 Rev: 1-74 3/75 # <br />