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1 <br /> ^ Cmc It V&d <br /> SAN JO <br /> AQUIN LOCAL ,HEALTH DISTRICT <br /> s "0"rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �! f Telephone (209) 466-6781 <br /> Y APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I.YEAR FROM DATE ISSUED Date Issued , �- p <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 U U CENSUS TRACTI <br /> Owner's Name b Phone <br /> Address Cil Al 0 City <br /> 3 <br /> Contractors . <br /> License �Fhone _ -' <br /> Name -7E7 G <br /> s 4 <br /> h N <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -47 RECONDITION /=T DESTRUCTION /7 <br /> PUMP INSTALLATION /7 PUMP REPAIR /FPUMP REPLACEMENT I T <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 <br /> Industrial `a Cable .Tool Dia. of Well Excavation <br /> Doestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> G Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal ' Other Other Information <br /> Geophysical i Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> s <br /> Typeof Pump <br /> H.P. 13c9 <br /> k <br /> PUMP REPLACEMENT: '.State Work Done ✓ "� <br /> PUNP `.REPAIR: /7 ! State Work Done - <br /> PES-TRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Desciibe 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. tne..well in.use. The above <br /> information is true to the-best of my ledg and�b f. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPE -ION. <br /> -- �„! TLE <br /> I SIGNED (DRA P . ON REV SE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I DATE 3 7 <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS: •,, <br /> PHA I T INSPECTI PHA I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> 1-74 2M <br /> E H*1426 -,Rev. 1-74 <br />