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SAN JOAQUIN LOCAL HEALTH: DISTRICT <br /> [FOP, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> =-APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4_-a27 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t <br /> and/or install the work herein described. This application is made in compliance with San Joaquinf <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin. Local Health District. <br /> JOB ADDRESS/LOCATION 0' <br /> tat CENSUS TRACT <br /> Owner's Name ss 4.0 Phone F <br /> Address City . <br /> Contractor's NameLicense # (y_ 3 zr Phoney -1, -74 <br /> 6 f <br /> f <br /> TYPE OF WORK (Check).: NEW WELL/ / DEEPEN /_% ~RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/y / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> m 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 Cable Tool mDia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ' <br /> }c Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �. <br /> u Disposal , Other Other Information <br /> Geophysical Surface 'Seal Installed BY: <br /> PUMP INSTALLATION: Contractor � r4 <br /> y Type of Pump k 0. V H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /x/ State Work Done. <br /> t n � <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 Zklecdl,�ge—and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL E <br /> SIGNE TITLE. <br /> RAW P16- LAN ON R RSE SIDE) <br /> , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> -�, - <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE . <br /> E H 1426 Rev. 1-74 �. 1117 _ 2M <br />