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/. _k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR. OF CE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Ar Telephone: (209) 465-5781 <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 to the Sam 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 Joaquin4 <br /> County Ordinance No. 1852 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> f("Ogg X_ ST-o"') <br /> JOB ADDRESS/LOCATION / �0 CENSUS TRACT <br /> Owner's Name Phone i <br /> .Address s- 7 � � � (,� � h <br /> »•( City ,�pct spa-rte <br /> Contractor's Name ri} License #/ LX'Phone ie 7dz <br /> k <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN •/ 7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR /x/ PUMP REPLACEMENT /_7 <br /> ' Other <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY . CIP <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER € <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL h <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 /> )e ..Irrigation A Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection r Rotary Type of Grout <br /> :__.__...Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor J f <br /> ' Type of Pump H.P. Zf <br /> i <br /> PUMP REPLACEMENT: / IT State Work Done <br /> PUMP '.REPAIR; / C%_7 State Work Doneu -o �o«e1 <br /> Go u�rr ►� �� <br /> ES:TRUCTION OF WELL: Well Diameter Approximate Depth <br /> b Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sacs Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS I <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 knowledge-anH elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND-A FINAL INSPE 10 <br /> SIGNEDTLE ' <br /> /(DRAW PLOT PLAN ON SE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I " . <br /> APPLICATION ACCEPTED BY DATE '1 <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSRECTION PHASE III FINAL INSPECTION f <br /> INSPECTION BY DATE INSPECTION BY ,� DATE <br /> E R 1426 Rev. .1-74 1-74 2M <br />