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C4. �6SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> �g <br /> FOR:OF ICE USE: V1601 E. Hazelton -Ave. , Stockton, Calif. <br /> -• Telephone: x(209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Issued X76 <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 <br /> � ENSUS TRACT . . <br /> Owner's Name Phone <br /> Address a _ City <br /> Contractor's Name License U221 Phone -��71` <br /> . . <br /> TYPE OF WORK (Check): NEW WEL /_7 DEEPEN '/: RECONDITION /_f DESTRUCTION /_7 <br /> :,. PUMP INSTALLATION - PUMP REPAIR -7 PUMP REPLACEMENT <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 p <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 /> r <br /> Cathodic Protection Rotary - - Type of Grout <br /> Disposal Other <br /> -, <br /> T� Other Information " <br /> Geophysical Surface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ., H.P. <br /> PUMP Al===litk / / State Work Done <br /> PUMP 'REPATR: -"'. /% State Work Done',,_ _ � , , •,„ � � �;c,e3 x ,....,�...,. <br /> DESTRUCTIONOF 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 before putting..the..well. in.use... .The above <br /> information is true to the-best'of m .kn 1 e an belief. I WILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR TO GAOL1 TNG `AND A FINAL INS CT <br />.SIGNED - TLE <br /> ( W PL LAN ON RE I SE SID . . <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE � . <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS1_1I/F1jRAL INSPECTIOIP <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />