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Y SAN JOAQUIN LOCAL HEALTH. DISTRICT " <br /> FOE :9 APeE -USE: 1601 E. Hazelton Ave. , Stockton, Calif:.,,.-, <br /> Telephone: (209) 466-6781 <br /> APgLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7 <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 Joaq�iin <br /> County Ordinance No. 1862 and the Rules and Regul ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION [,� NSUS TRACT _ <br /> Owner's Name Phone <br /> Address City <br /> Contractor'sName_^a License �� Phone <br /> TYPE OF WORK (Check) : NEW WELL EPEN '/_/ f'R.EGOND.ITION f_1 DESTRUCTION /_ <br /> r ° 'PUN1PrINSTALIaATION""/_/ ""PUMP'--REPAIR--/-'/""1'CTMP-REPLACEMENT 1-7 - <br /> _ - - <br /> Other <br /> • � N <br /> DISTANCE TO\:NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL G` <br /> INTENDEL). USE TYPE OF WELL CONSTRUCTION SPECIFICAT ON �r <br /> Industrial Cable Tool Dia, of Well-Excavation-- - <br /> �mestic/private Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge of Casing k� A <br /> Irrigation Gravel Pack Depth of Grout Seal' `-� f <br /> Cathodic Protectiontary Type of Grout A - <br />+, Disposal Other _ Other Information'` <br /> Geophysical Surface Seal Installed B : <br /> 3 <br /> PUMP INSTALLATION: Contractor <br /> s Type of Pump 5 H.P. <br /> PUMP REPLACEMENT ri / / State Work Done / <br /> PUMP .REPAIR: / `/ State Work Done J <br /> DESTRUCTION OF WELL: Well Diameter _. _ .-Approximate Depth <br /> Describe .Material and Procedure <br /> 4 <br /> I,hereby agree to comply withtalllaws and regulations of the San Joaquin Local Health District <br /> and the State of California pertain'i.ng to ,or regulating well'c ruc } Within FIFTEEN DAYS <br /> after completion of my work on\a new well, I will furnish t. San J•oaqui Local Heal District a <br /> WELL DRILLERS REPORT of the welA�_ an notify them before pu ting the -well in use. T e above <br /> information is t to the besty°knowledge and belief. I WILL CAL FOR A G NSPECTI� <br /> PRIOR TO GRO D A FINAL I <br /> SIGNED TITLE - <br /> 0! DRAW PL T' PLAN ON RE RSE S <br /> FOR DEPARTMENT USE ONL <br /> PHASE I <br /> APPLICATION ACCEPTED BY i DATE "�✓G� <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION r. _ PHASE III/FIDIAL INSPECTION <br /> INSPECTION BY DATE Gam% 7 ' INSPECTION BY DATE <br /> 3/76 2M <br />� E...H 1426 Rev. `1--7.4 . . _ <br />