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ea t �� d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL 4IFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ? APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��-/z"5_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //-3=7G <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 qCENSUS TRACT <br /> Owner's Name woo 7Id`-�►•�d Phone <br /> s L]D <br /> Address o�6 b �Le�✓�B� ,/,/ d d to City <br /> Contractor's Name <br /> License 7 w-Phone G s•-�d 76 <br /> "4 1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN // RECONDITION_/ / DESTRUCTION /? r <br /> PUMP INSTALLATIONLX PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> � 1 <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 /> 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 /> I Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor , ! <br /> Type of Pump H.P. 3-- <br /> Don <br /> e <br /> •�J <br /> PUMP /)c/ State Work <br /> , <br /> PUMP .REPAIR: / / State Work Done <br /> DES•TRUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree ree to comply with all laws and regulations of the San Joaquin Local Health District <br /> AYS <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN D <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 /> information is true to the best of. owledg d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T0::2-R TING .AND A FIN IQN <br /> SIGNED _ TITLE <br /> DkW PT ' PLAN ON ERSE SI17E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE /0 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II -GROUT INSPECTION DATE c. � <br /> r INSPECTION BY DATE INSPECTION BY <br /> 3/7 <br /> �' E H 1426 Rev. 1-74 --- <br />