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V _ —... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOAeOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date.-Issued <br /> (Complete In triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distr;.ct for a pest 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 O ovi o CENSUS TRACT <br /> Owner's Nacre G i' i Phone <br /> �.zz 6 <br /> Address o a ,'o City <br /> Contractor's Name <br /> c License #.Z vo'7PK Phone <br /> TYPE OF WORK (Check): NEW WELL -/? DEEPEN /_7 RECONDITION &' DESTRUCTION f7 <br /> PUMP INSTALLATION /� PUMP REPAIR /_7 PUMP REPLACEMENT f7 <br /> Other rH 2l�71 a,41-le, !�/�!/ r <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 <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 Q <br /> Cathodic Protection Rotary' Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P...., <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /7 State Work Done <br /> ES-'£RUCTION OF WELL: Well Diameter Approximate Depth - =� <br /> Describe Material and Procedure <br /> I 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 o he well and notify them before putting.the..well in-use.. The above <br /> information is tru o - he-b my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO INAL I ION <br /> SIGNED TITL <br /> (DRAW PLOT FLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I;&/FINAI.71NSPECTION <br /> INSPECTION BY DATE INSPECT ON BY DATE ,/,2-//-7J� <br /> w <br /> E H 1426 Rev. 1-74 <br /> 1-7 2M <br />