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.:? . , `• - SAN JOAQUIN LOCAL HEALTH DISTRICT U' <br /> 'FOH OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7Z1�12 - <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED f Date Issued O - "7 <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 , Q ] .� �jip _ CENSUS TRACT _ <br /> s r Phone $ r � 3 <br /> Owner's Name r <br /> Address. O- D 0 g - µ City <br /> Contractor's Name t �l G G O License # 3 2 1� �ZPhone ! ��7�'.3 <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN`/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION IX/ PUMP REPAIR J / PUMP REPLACEMENT IT <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 611 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal T. <br /> Cathodic Protection Rotary Type of Grout �p�TO <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By : <br /> . PUMP INSTALLATION: Contractor <br /> Type of Pump tL 0— H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> Approximate Depth l�Q <br /> DESTRUCTION OF-'WELL':— Well Diameter Cp pp - <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations oT ,;the San Joaquin Local Health District <br /> r - . <br /> and the State of California pertaining ro or regulating well constfuctidn: Within FIFTEEN DAYS <br /> after completion of my work 'onanew well, I-�wi-ll -furnish the San Joaquin Local Health District a <br /> t 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 GROUPING AND A FINAL I SPECTION. <br /> SIGNED � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) F <br /> ► FOR DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �-- <br /> ADDITIONAL,COMMEN.T.S.:- --�— <br /> 4 PHASE . I ROUT INSP CTION s i'HASE IT FI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1426 Rev. - I-74 <br />