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E: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORtOr71tE USE: `3 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ii <br /> j-, F/C-,. Telephoner (209)-'466-6781 <br /> i� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z`7 <br /> i!. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or1install the work herein described. This application is made in compliance with San Joaquin <br /> County !Ordinance No. 1862a and the Rules and Regulations- of the San Joaquin Local Health District. <br /> Z4 <br /> JOB ADDRESS/LOCATION ? f r U CENSUS TRACT <br /> Eh . <br /> Owner's Name �o?rl /7a !� __-- — Phone <br /> I� - <br /> Address "07/r `'.��� City f�G /R <br /> r ,21219 49 - -- <br /> Contractor's Name r! �3' License # Phone 6 ��� �} <br /> TYPE 0!F WORK (Check) : NEW WELL DEEPEN / RECONDITION /_/ DESTRUCTION /-7 <br /> I PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> a • <br /> DISTANCE TO NEAREST: SEPTIC TANK _ate SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER W <br /> PROPERTY LINE PRIVATE DOMESTIC WELL. _ PUBLIC DOMESTIC WELL �! <br /> IN, INTENDED USE TYPE Off' WELL� CONSTRUCTION SPECIFICATIONS 4 <br /> `..Industrial , Cable Tool Dia. of Well Excavation <br />___Z,,::::: E]}omestic/private Drilled Dia, of Well Casing _ <br /> 7Nomestic/public Driven Gauge of Casing <br /> :Irrigation Gravel. Pack Depth of Grout Seal � <br /> Cathodic Protection' Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical p Surface Seal Installed By: _ 1 <br /> . 3 <br /> PUMP INSTALLATION Contractor <br /> ,• Type of Pump H.P. - <br /> PUMP REEEPLACEMENT: /YY,_/ State Work Done gg <br /> PUMP .REPAIR: / " /'� State'Work�Don <br /> DES-TRUICTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia Proced <br /> I hereby agree to comply with all laws and regulati ns 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 not i.fy them before putting. the- well in use. The above <br /> information is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ATO GROUTING - A FINAJ,,.I PECTION. *�. <br /> SIGNED `' TITLE Vw6. Y <br /> I, - _ (DRAW PLOVPLAN ON REVERSE SIDE) <br /> EiE� FOR DEPARTMENT USE ONLY _ <br /> PHASE.I i I \. <br /> APFLICATION ACCEPTED-BY. * V "' - DATE <br /> ADDITIONAL 'COMMENTS: _ ' <br /> P G UT INSPEC PHASE III/FINAL INSPECTION <br /> INSPECTION BY , INSPECTION BY DATE <br /> 9 S 4 <br /> E H 1426 Rev. - l-74 " <br />