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60P>< 16 itcy( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF-5-K, OFF _CT USE: 160" 7. Hazelton Ave. , Stockton, Ca] -117 � 1� <br /> ""Telephone: (209) 466-6781 ~' <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ' 71 <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 3 �� L,L�= p5 0t/ te CENSUS TRACT <br /> Owner's Name &tlkl (b Phone <br /> Address .9 , f}- y- City <br /> Contractor's Name �, License # /E 7x r1h-one 7,�7_vl <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR jg/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEA ST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> fm e- h SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 7 *I;l J.S-J4 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 <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 p <br /> Geophysical Surface Seal Installed By: j}o <br /> PUMP INSTALLATION: Contractor � R . F <br /> Type of Pump H.P. / ,e <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /X/ State Work Done j f7r i " <br /> DESTRUCTION 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 m owled a and)- elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPE ON. <br /> SIGNED_ - z ITLEc <br /> ( W LO AN ON RE SE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BYD ATE INSPECTION BY DATE 7 7 <br /> 1177 _ 2M <br /> E H 1426 Rev. 1-74 <br />