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r <br /> f ,Ce9 lct ar Cie - SAN JOA <br /> QTJIN LOCAL HEALTH DISTRICT <br />` FOFi:OFF E USE: 1601 E. Hazelton Ave' . , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTIQN OR PUMP PERMIT Permit No. 7-T'-' � <br /> t 6 <br /> THIS PERMIT" EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - .-715- <br /> {Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District fora 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 1 `G SL C ,.4nO?. c* CENSUS.TRACT <br />` Owner's Name M <br /> ` Phone ' <br /> Address a TZ 7 � <br /> City <br /> Ir Contractor's Name - .. �4 <br /> License V"hone 4 <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/-7- RECONDITION / DESTRUCTION / <br /> PUMP INSTALLATION -4e PUMP REPAIR -/-7—PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT "OTHER S <br /> 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 /> w Domestic/private Drilled Dia. of Well Casing ' <br /> Domestic/public Driven F. ....:s 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 'B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. / <br /> PUMP REPLACEMENT: , /% State Work Done i <br /> PUMP lecom: 1)�/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - . <br /> Approximate Depth <br /> Describe Material and Procedure ; <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District r <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 weld and notifythem before <br /> putting the..well. in.use.... The above <br /> information is true to the best. my.".knowle e a d belief. T WILL CALL FOR A GROUT INSPECTION <br /> PRIOR fi0 0 ING AN A FINAL INS ION 1 <br /> SIGNED ITLE ' <br /> { RA P T. ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ITUFINAL INSPECTION <br /> jNSPECTION BY DATE INSPECTION BY DATE <br /> EH .426 Rev. . 1-74 1.1,e <br />