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h/Q r&r ,,r �j <br /> ,• SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF USE: 1601 E. Hazelton Ave. ,- .Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> J� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 0Issued <br /> ;I (Complete In'Triplicate) <br /> APr lication,,istereby 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.- CENSUS TRACT <br /> Owner's Name Phone <br /> Address City , c r� { " <br /> Contractor's Name License ILKK3LLy Phone <br /> TYPE OF WORK (Che7ck-) ;'--NEW-WELL / DEEPEN /_/ RECONDITION/-/' `DESTRUCTION i-/7 <br /> r <br /> PUMP :INSTAD ATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> L, f • Other. <br /> I, <br /> DISTANCE TO NEAREST: SEPTIC JTANK J) -EWER LINES ---PIT PRIVY �---� , <br /> SEWAGEEDISPOSAL FIELD ---CESSPOOL/SEEPAGE PIT --�_ OTHER .--- <br /> PROPERTY LINF tPRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Y Cable Tool Dia. of Well Excavation y <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dothestic/public Driven Gauge of Casing (� <br /> Irrigation t` Gravel Pack Depth of Grout Seal - <br /> Cathodic Protection 1 Rotary Type of Grout _ <br /> Disposal Other Other Information --- <br /> Geophysical Surface Seal Installed By:_ <br /> � C W �•GL S���n rv,Tr�- <br /> PUMP INSTALLATION: Contraction " t ( a /"d L- L ►`�'� <br /> Type 0,.' Pump H. . . . . <br /> PUMP REPLACEMENT: / / State Work Done" <br /> ° J. <br /> fit• [ !'T <br /> 4 PUMP_•.REPAIR: _ / / .w State :Work Done <br /> � 1 — � roximate Depth <br /> De dr . <br /> DES.TRUCTTON� OF WELL: Well Diameter . f , Approximate- P <br /> Describe Material>;,and Procedure } <br /> I hereby,agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> hand the .State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> l 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 Ewell and not <br /> y them before putting the well in use. The above <br /> information is true to the b t k - edge and belief. I ,WILL CALF. FOR A GROUT INSPECTION <br /> 1PRIOR T G AN A FIN I Em <br /> SIGNED - TITLE nt s <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> :i FOR DEPARTMENT USE ONLY <br /> PHASES I r L� .�• �� T- i . <br /> APPLICATION ACCEPTED BYx- DATE I ' , <br /> ADDITIONAL 1 COMI+MENTS: <br /> .__ __ ____. u PHASE I FINAL NSPECTI <br /> PHASE II GROUT INSPECT10 { a 3 <br /> INSPECTION-2 ... �vDATE ' ' - "INSP-ECTION�B' . ATE- " - <br /> E H-1426 Reu. 1-74 i. <br />