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117 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO& OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif." <br /> Telephone: (209) 466-6781 `' - <br /> (APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMA <br /> /90- THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> (Complete In Triplicate) <br /> Application is Aere y- 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 zaes d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �5 �sCENSUS TRACT <br /> Owner's Name d Phone <br /> Address j�� City <br /> Contractor's Name � n License 4 Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTYATION — PUMP REPAIR PUMP REPLACEMENT <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 4----Drilled Dia. of Well Casing <br /> .4-'Domestic/public Driven Gauge of Casing -�^ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _A,,z, Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical �Surflace Seal Installed By: <br /> PUMP INSTALLATION: Contractor ( C-� wrw,/ -144Z,67J <br /> Type of Pump H <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / ,$,tatey Work D'he <br /> f7"Crl� G,,•� C. �.' ¢c,� <br /> DESTRUCTION OF WE L Well Diameter 4�-t�c -�C,2.Z i}� �%*4 roximate Depth <br /> Describe Material find Procedure <br /> I hereby agree to comply wi h -a1._1_jAws 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 /> inforLwation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T GROUTING AND A INAL INSPECTION. <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY © w,,7 e ra,y <br /> PHASE I �7 <br /> APPLICATION ACCEPTED BY li/ /� DATE <br /> ADDITIONAL COMMENTS: <br /> z <br /> 'p' <br /> PHASE II GROUT INSPECTION PHAS I I/F NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1- 4 <br />