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FOR; IFF CE USE: SAN JOA.QUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,W S9J4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> Application is hereby made to the Sano gain Local Health District for a �'� ad._1y' <br /> and/or install the work herein described. This application is made in compliance to Construct <br /> County Ordinance No. 1$62 and the Rule and Regulations of the San with San Joaquin <br /> /3ctlfj� � Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION <br /> 14'eO-r- CENSUS TRACT <br /> Owner's Name _t 0�A� ,I "i _­­� <br /> Address to A4 <br /> Phone <br /> Contractor's NameCity 4 d <br /> � License # � <br /> _ Phone ,� Q <br /> TYPE OF WORK (Check): NEW WELL. l�r DEEPEN / / RECONDITION /? DESTRUCTION <br /> r PUMP INSTALLATION /9'- P� REPAIR /—/ PUMP REPLACEMENr7-]' <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK ____ <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT_ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL p OTHER <br /> INTENDED USE TYPE OF UBLIC DOMESTIC WELL Industrial a CONSTRUCTION SPECIFICATIONS ~ <br /> !�Ifomestic Cable Tool Dia. of WeII Excavation <br /> /private Drilled <br /> Domestic/public —�-- Dia. of Well Casing (� <br /> Irrigation Driven Gauge of Casing <br /> Cathodic Protection `— Gravel Pack Depth of Grout Seal <br /> Disposal —,�_ Rotary Type of Grout <br /> Other Other infor;nat on 'c , <br /> Geophysical �--- <br /> -F Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump It--�� <br /> PUMP REPLACEMENT; // State Work Done <br /> PUMP IRE ` <br /> State Work Done <br /> ES TRUCTION DF WELL; Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulation$ of the San Joaquin Local Health Distr <br /> and the State of California pertaining to or regulating well construction. icS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before Within FIFTEEN DAYS <br /> information is true to the best of m Putting the.-well in use.. The above a <br />'RIOR TO GROUTING AND A FINAL INSP CTI N knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSETLE SIDE�� <br />%ASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By <br /> DDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY DATE PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />