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.SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> fi <br /> FOP,,rOFF .CE XSE: L 1601 E. Hazelton Ave. , Stockton, Califr., <br /> _ <br /> Telephone: (209) 466-6781 i <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 Realth District fora 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 /> 60 <br /> JOB ADDRESS/LOCATION - t:1 0 r,;P,, S e4e xxoea CENSUS TRACT <br /> Owner's Name. r.i-� Phone <br /> Address 2/ ✓Gi ! !ice City <br /> Contractor's Name License # 76 e d <br /> l�-7 phone <br /> 104, <br /> 6 <br /> TYPE..OF WORK (Check): NEW WELL I-7 DEEPEN ,/-7 RECONDITION /_7 DESTRUCTION f-7 <br /> PUMP INSTALLATION / / —PUMP' REPAIR Z PUMP REPLACEMENT J <br /> Other <br /> DISTANCE TO.NEAREST: SEPTIC .TANK . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL O <br /> INTENDED- USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS d <br /> Industrial Cable Tool Dia. of Well Excavation <br /> € Domestic/private Drilled Dia: of Well Casing , <br /> Domestic/public Driven Gauge of Casing 6 <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 i <br /> PUMP REPLACEMENT: / / State Work Done t7.. <br />`. PUMP :REPAIR: Cf State Work Done ` <br /> ,SES RUCTION 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 5 <br /> sand .the State of California pertaining'to or regulating well construction. Within FIFTEEN DAYS <br /> After. completi;on 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. puttingthe.-veil in-use.. The above <br /> information is true to", the-best of. my kno dge, a e 4 of; I WILL CALL FOR I GROUT INSPECTION <br /> PRIOR,TO GROUT NG 'AND,A FINAL INSPECTION. ' <br />` SIGNED`. r , . JqXTLE ��.C' <br /> {DIAP T P ON REV SE SIDE - <br /> F DEPARTMENT• USE ONLY <br /> PHASE I a . . <br /> APPLICATION";ACCEPTED:BY DATE Z117//� i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Z F AL INSPECTION <br /> INSPECTION BY . DATE. " INSPECTION-BY ATE . <br /> l.t - E H 1426 . , Rev. 1°7.-74 . 1-74 2M <br /> "_ <br />