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SAN JOAQUIN LOCAL HEALTII DISTRICT <br /> FOR OFFICE USE: 160:%W' Hazelton Ave. , Stockton, Calm <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T4i_3c�ya <br /> _ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?,9-7 q <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ad/or install the work herein described. This application is made in compliance with San Joaquii <br /> county Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> )B ADDRESS/LOCATION 1 �] 3 3 CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> dress / r City <br /> antractor's NcfT�sJ� :. 6� f �r cense # Phoned- <br /> e� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> [STANCE 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 u` <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 <br /> Geophysical rSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor c�iV / - ; •� <br /> Type of Pump ,� rs H.P. <br /> PUMP REPLACEMENT: / State Work Done /at a,i %aI ./ Z6, <br /> TMP ,REPAIR: / / State Work Done <br /> )ES•TRUCTION 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 /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> :ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> n,LL DRILLERS REPORT of the well and notify them before putting thewell in use.. The above <br /> information is true to the best of m__know dge and b lief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO G AND FINAL IO ( w. <br /> ,-iGNED TLE <br /> r� <br /> ( OT ON RE RSE SIDE- <br /> FOR DEPARTMENT USE ONLY <br /> ..LASE I r <br /> APPLICATION ACCEPTED BY DATE J <br /> ►DITIONAL COMMENTS: <br /> _ PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 / 1_7A W <br />