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:N <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: ' 601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone: (209) 466-678.1 <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 .toIthe 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 /> i <br /> JOB ADDRESS/LOCATION Q&el" 6 • 14 LV ;2,0CENSUS TRACT <br /> �-y r <br /> Owner's Name _ ?v Phone 9 32977 <br /> Address J City L,s G 4)4 ru <br /> Contractor's Name I'�� I License # -7y010 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /% DESTRUCTION /_ <br /> PUMP INSTALLATION L <br /> jk7 PUMP REPAIR/ / 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 <br /> Industrial ! Cable Tool Dia, of Well Excavation �1 <br /> Domestic/privateer ! Drilled Dia, of Well Casing G <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation •_ -^------i ---Gravel Pack --� — -Depth--of •Gr-out--Seal--._— , <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ! Other OtheF-Information <br /> —Geophysical -8urface-Seal Installed By: � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump -- � { :f- ; : H.P. <br /> PUMP REPLACEMENT: . i �+ <br /> St;ate;T�+Tork Done ,_ ' <br /> PUMP .REPAIR: / / State ;Work Done ± <br /> DES-TRUCTION 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 thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> PRIOR TO UTI AND A FI �NSPECTION. <br /> SIGNED V. <br /> TITLE <br /> D W Pi T FLAN 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT I SPECTION PHA F INSPECTT <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev, -1--74 <br /> 3/76 2M <br />