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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FZCE USE: / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1� � <br /> late Inf <br /> Application is hereby made to the San(Joaquin LocalrHealth 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 / 2 <br /> l� rt CENSUS TRACT <br /> Owner's Namejr7! G !�/ Phone <br /> -� <br /> Address _ --A.-AZ.R.P f--- S �L f 0I1.,L �j� '�a <br /> City <br /> Contractor's Name of/ Zp License #/ � <br /> 7 hone C J-7� 6 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /—T RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_J PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V`J <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 /> x _ 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 Bv: <br /> PUMP INSTALLATION: Contractor, <br /> Type of Pump B.P. <br /> PUMP REPLACEMENT: /k/ State Work Done `� h <br /> 1122 :REPAIR: /7 State Work Done V 6f <br /> pESTRUCTION OF 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 my knowledge and be ef. I WILL CALL FOR A GROUT INSPECTION <br /> 4 <br /> PRIOR TO G G AND A INAL INS N, <br /> SIGNED <br /> D P P N -SIDES-7T' <br /> PHASE I K D TMENT USE ONLY <br /> APPLICATION ACCEPTED DATE <br /> A -TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY DATE (9 <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />