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f 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O'FFICT'USSE: U 1.601. E. Hazelton Ave. , Stockton, Calif. <br /> # Telephone : (204) 466-6781 : <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit -No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 hereinldescribed. This application is made in compliance with San Joaquin` <br /> County Ordinance No. 1862 andj!the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r..(��t 7wn o 4z,(— A4, i ;,z CENSUS TRACT <br /> � ,Q fi �1 <br /> Owner's Name Li �lL 6�'"�t �I Phone <br /> Address aPao 0 -A-d City _ <br /> Contractor s Name P! License # � Phone <br /> �1 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/�/ RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_7 <br /> Other A-1 ; <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 it Cable Tool Dia, of Well Excavation <br /> Domestic/private jt Drilled ? Dia. of Well Casing <br /> Domestic/public t Driven z Gauge of Casing # <br /> Irrigation Ft Gravel Pack' Depth of Grout Seal <br /> Cathodic Protection A Rotary Type of..-Grout <br /> Disposal it Other Other Information <br /> Geophysical Surface Seal Installed By : + <br /> PUMP INSTALLATION: Contractor <br /> Type ofPump H.P. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Donea t- <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 bes_'t of my, no ed e of ' <br /> be ef. I WILL CALL FOR A GROUT INSPECTION <br /> O <br /> PRIOR TO G G AND FINAL <br /> SIGNED TLE ' . <br /> (D [,1 OT AN ON RE SE SIDE) -- <br /> R DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY ��yy J - - DATE /z -77 <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION P E II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTIO BY DATE <br /> 2M <br /> E H 1426 Rev. - I-74 C <br />