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SAN JOAQUIN LOCAL HEALTH DISfiRICT <br /> 10C-O ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /-7y-_ q/Ifo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is% eby made to the San Joaquin Local Health District for aP ermit 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 d`-IC �'�' CENSUS TRACT <br /> Owner's Name 6 14,7� Alk- Phone <br /> Address �--:.- tom/ ,� .r ,�' d City cSa c%rt <br /> Contractor's Name License #/ 3 yj Phone ja.X -";" i <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / J PUMP REPAIR /-7 PUMP REPLACEMENT /f <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 ? <br /> 7C Domestic/public Driven Gauge of Casing <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 <br /> Type of Pump H.P. �J <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP Sj?S� State Work Done ,j � k o,•°l-,- Clc �..� -re sftr / <br /> ,2ES-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 bef re putting thewell in use.. The above <br /> information is true to the best of y owl &e and ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND ,A FINAL IN N. <br /> SIGNED ._ <br /> E / d° <br /> RA LO ON REVOKE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A— <br /> ADDITIONAL <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> VO <br /> ti E H 1426 Rev. 1-74 <br /> 1-74 ZM <br />