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e6 /a SAN JOAQUIN LOCATE HEALTH DISTRICT �P <br /> FOF 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. I <br /> Telephone: (209) 466-6781 _/��v <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 3 <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 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 S ���, �n �,p,,�. � �� dE 5F.9-7o-S-.: , ;ENSUS TRACT <br /> Owner's Name - +-- Phone -- T <br /> Address a'7�. f City - -- <br /> Contractor's Name s.r '`' License # l¢3�J4S Phone <br />' TYPE OF WORK (Check) : NEW WELL / / DEEPEN/�/ RECONDITION / DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other t/ / <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 Cable Tool Dia. 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 \�1 <br /> Cathodic-Protection Rotary Type of Grout V <br /> Disposal Other Other Information _ <br /> Geophysical �:_. Surface Seal Installed By: _ <br /> f- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pum H.P.. �z�T <br /> PUMP REPLACEMENT: / / State•-Work Done <br /> PUMP REPAIR: /?r/ State=,Work" Done <br /> Gu O <br /> fDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sari 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 <br /> WELL DRILLERS REPORT of the dell and notify them before putting .the well in use.. The above <br /> information is °true to the best of my know edge belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEC 0 , <br /> SIGNED fTLE �� -- <br /> P PL LAN ON RE SE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY­.--- iC (y�,2G,., DATE <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II ROUT :INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY aJ DATE //_,t)/77 " 2m <br /> E H 1426 Rev- 1-74 <br />