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L/�Val-� <br /> — SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� O Fllt CE U5 : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71-,3/3 p <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 Health District for a permit to construct <br /> and/ov install the work herein described. This application is made in compliance with San Joaquin <br /> iCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION D m fX CENSUS TRACT <br /> Owner's Name 01"_do's :E! e-�.,_..._ .� Phone <br /> Address D W i �o City <br /> Contractor's Name PC - . • License # L1Phone , <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ /PUMP REPAIR/ 7 PUMP REPLACEMENT <br /> Other j/7 <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 s� <br /> Domestic/public Driven Gauge of Casing �A <br /> Irrigation Gravel Pack Depth of Grout Seal i\ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface_Seal Installed By: <br /> PUMP 1NSTALL4,TIONa Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT:— / / State Work Done <br /> -PM 'REPAIR: / / State Work Done <br /> bESiTRUCTION OF WELL: Well, Diameter Approximate Depth a <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-the.-well- in-use.. . The above <br /> information is true to the-best of my.. o edge an lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG U ING AND A FINAL INSPECTION. <br /> SIGNED LE <br /> DRAWP T P N REV SE SID�� <br /> DEPARTMENT USE ONLY <br /> PHASE 1 <br /> APPLICATION' ACCEPTED BY ✓ DATE -7 `7 6 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P INSPECTION <br /> INSPECTION BY DAT <br /> r, INSPECTION BY DATE <br /> E H 1426 Rev. 1-744/75 ZK <br />