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FOPp ,I , — SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E USE: .1601 E. Hazelton. Ave. , Stockton, Calif. !� <br /> '. Telephone : (209) 466-6781 <br /> 3. APPLICATION FOR"WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1• YEAR FROM DATE ISSUED. <br /> f- / Date Issued tc,2 8 <br /> ;Application is here (Complete r <br /> by made t'� the San Joaquin LocalHealth�District; for a. . ermit to construct <br /> I ' and/or install the -work herein described, . This application is made in compliance with <br /> P <br /> County Ordinance 'No. .1862 and the Rules and Regulations of the San Joaquin Local- He San actin <br /> Local- Health District. <br /> JOB ADDRESS/LOCATION <br /> -.,.•.,y§ - r? L1 ct t.� y�,6 CENSUS TRACT <br /> Owner's Name / <br /> CG I� kl [ < � 1d .. <br /> Phone <br /> Address <br /> city jjjk <br /> Contractor's Name <br /> - �--a License <br /> Phone 'Y �6 , <br /> TYPE OF WORK (Check) : NEW WELLti • � ` <br /> / DEEPEN /_/ 'RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other — \t <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PST PRIVY . <br /> SEWAGE DISPOSAL FIELD CE_ Ell: <br /> PIT OTHER ' <br /> PROPERTY+ LINE - PRIVATE DOMESTIC WELL, ST <br /> PUBLIC DOMESTIC WELL _ <br /> INTENDED USE TYPEOF WELL <br /> Industrial ACable Tool CONSTRUCTION SPECIFICATIONS <br /> Domestic Dia. of Well Excavation <br /> /private 1 Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven <br /> Irrigation Gauge of Casing <br /> H Gravel Pack Depth of Grout Seal <br /> Cathodic Protection <t Rotary Type of Grout <br /> Disposal t. Other . YP <br /> Geophysical Other Information <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4 � .{ <br /> H.P, <br /> NT: <br /> _ <br />'UMP REPLACEME J1C/ State Work Done <br />'UMP .RF,PAIR: / / State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe' Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations pof-the San Joaquin Loc <br /> nd the State of California pertaining to or re ulatin q al Health District <br /> fuer completion of my work on a new well, I will furngishethecSantJaaqu�n.Localhin Health�DistEEN DAYS <br /> ict a • <br /> ELL DRILLERS REPORT of the well and notify them before putting thewell in use:. . The above <br /> nformation is true to the bestlof. my knowledge and belief, <br /> 3IOR TO GROUTING ANB A FTNA SP O R I WILL CALL FOR A GROUT INSPECTION <br /> IGNED N <br /> 'IT LE <br /> 1 ( W PL T PLAN ON4 <br /> SE SIDE) <br /> iASE I FO DEPARTMENT USE ONLY ' <br />'PLICATION ACCEPTED „ <br />)DITIONAL COMMENTS 14 DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> JSPECTTON BY � DATE INSPECTION BY <br /> e �- DATE <br />�E H 1426 Rev- 1-74 <br /> - 0. 77 ona <br />