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CO step/040( SAN JOAQUIN LOCAL HEALTH DISTRICT b <br /> FOF OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 9 F <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/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 6 g',3 /� .21, CENSUS TRACT <br /> Owner's Name `✓ Phone <br /> Address - 24 CityAd A <br /> Contractor's Name License # J 372.SPhone 2-7d71 <br /> y. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /—/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR/}/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY • c� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER R <br /> PROPERTY LINE 7 PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1! <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 /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .-:; -fpr H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /tel State Work Done �d ZZ /%_ _ ! <br /> DESTRUCTION OF .WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Taws 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 puttingthewell in. use. The above <br /> information is true toMthe best of my,-kpowledge and-belief. I WILL' CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECT ON, <br /> SIGNED . /�LE <br /> ( tiI P T nATOIN kLEVXKbh SIDE) ;F <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I /� <br /> APPLICATION ACCEPTED BY DATE (,a r <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I/ NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE # -7 <br /> 1177 2M <br /> E H 1426 Rev. 1 -74 _. <br />