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&,. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F-0—E.-OFFICE [FSE: 1601 E. Hazelton Ave: , Stockton, Calif. SCA <br /> -•`" Telephone: (209) 466-6781 N <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -4,91P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -q- -7S <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> rind/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 CENSUS TRACT <br /> Owner's NameC Phone <br /> Address /-d City ?y <br /> Contractor's Name o .. License # 'Thone <br /> TYPE OF WORK (Check) : NEW WELL '/? DEEPEN /__7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR . PUMP REPLACEMENT /7 <br /> Other <br /> -DISTANCE 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS LA <br /> �D6-wastic/pubiic <br /> Industrial Cable -Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Driven Gauge of Casing v` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> -Disposal Other Other Information, <br /> Geophysic-.al Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor 4 <br /> t Type of Pump H.P. -- <br /> PUMP REPLACEMENT /7 State Work Done <br /> PUMP ,REPAIR: State Work Done ,� 005/- <br /> DES T� RUCII_01. 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 be are putting the..well in use— The above <br /> information is true to the best of- m 1 <br /> we ge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING -AND A FINAL INTit <br /> SIGNEDUyTiTLE r <br /> LO P ON -RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' r TE ' -?s <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION E I N NSPECTIQX <br /> INSPECTION BY DATE INSPECTION1 Y AF,f' fi: DATE <br /> c <br /> E H 1426 Rev. 1-74 __ - 2M <br />