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CG Lr� 1 SAN JOA UIN L ry <br /> FOE.OFF E USE: 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.7S �D <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 rW CENSUS TRACT <br /> Owner's Name A/a11p A ,6 Phone <br /> AddresshD�- City <br /> Contractor's Name m License # jfA2_hj—'Phone g44 s..74 7L <br /> TYPE OF WORK (Check) : NEW WELL i7 DEEPEN '/7 RECONDITION %f DESTRUCTION f7PUMP INSTALLATION / / PUMP REPAIR/7 PUMP REPLACEMENT 27 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER + 1 <br /> MES <br /> PROPERTY LINE - PRIVATE DOTIC 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 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor CrfJ <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: State Work Dane <br /> PUMP .REPAIR: / / State Work Done <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 /> I information is true to the•best of my.kn wled a and b lief. I WILL CALL FOR A GROUT INSPECTION <br />' PRIOR TO GOUT NG AND A FINAL INSPE 0 . <br /> SIGNED <br /> .- ,. TITLE <br /> (D W OT P!AN ON RE SE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: L �. <br /> PHASE II GROUT INSPECTION, PHAS F INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY :' ATE q -f cfl-IS <br /> E H 1426 Rev. 1-74 V4/7'5 2M <br />