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Cd.G . .1�►' �� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OP ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 'Y <br /> Telephone: (209) 466-6781 <br /> 41 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-�-- � <br /> i THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In. Triplicate) ce7- 0'f0- 07 <br /> Application: is hereby made to the Son Joaquin Local Health DistAct for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Count Ordinance,No. 1862 and the Rules .and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCATION � ENSUE TRACT <br /> Owner's Name a � .,S .� �' hone - <br /> Address <br /> one -Address 106 / /V City , c <br /> Contractor's Name ".;�.� License # 'Zjj 7"'Phone 417674 <br /> 4 TYPE OF WORK (Check): . NEW WELL '/? DEEPEN.'/? RECONDITION /7 DESTRUCTION //-7 o <br /> r y PUMP INSTALLATION_/ PUMP REPAIR /W PUMP REPLACEMENT /? <br /> Other / f <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 x` <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled .� Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Groiet �. <br /> Disposal Other - OtherInformation S <br /> ' Geophysical - Surface Seal Installed 'B <br /> PUMP INSTALLATION- Contractor <br /> Type, of Pump ✓" H.P. <br /> PUMP REPLACEMENT: . /% State Work Done <br /> _ r � <br /> PUMP <br /> .REPAIR: p <br /> / / -State Work Done a, 1 �.•� a� r. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material: and Procedure <br /> 11 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 .of my..knedg and.�be1 ef. I WILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AI3D A FINAL INSPECT_.I0 ", <br /> SIGNED i <br /> DRAW P ON01 REVS "SIRE <br /> kBO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY `� DATEi <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Xi;/FM INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / ./ DATE '7,f' <br /> E`H 1426 Rev. i-74 <br />