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C4 6 1� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEi;Q FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued L_/,,2 � <br /> (Complete In Triplicate) <br /> Application is hereby :Wade 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 D I/Ca �,.ea �—A of CENSUS TRACT <br /> Owner's Name p 1-t •nm Phone ' <br /> Address g S`� <br /> T,.--� City <br /> Contractor's Name t w License # 7iiA hone 9��.1 <br /> TYPE OF WORK (Check) : NEW WELL �/7 DEEPEN ,/_7 RECONDITION/_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION —PUMP REPAIR/-7 PUMP REPLACEMENT /7 <br /> Other E7 -- <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS OP OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> „ Industrial Cable Took. 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 �h <br /> Type of Pump H.P. <br /> /p <br /> PUMP REPLACEMENT: . L/ State Work Done <br /> PUNP :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 /> information is true to the-best -of my.knowle belief I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSP N <br /> SIGNEDjT­ <br /> TLE <br /> (D T AN ON E SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />-APPLICATION ACCEPTED BY r� DATE <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION HAS I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY -777P U- WW <br /> EH- -1426 Rev. 1.74 /7K 9M <br />