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SAN JOAWUI-N .f. CAL HEALTH. DISTRICT <br /> FOR OFFICE USE: ®�! 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 914> <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J/-376 <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 Joaquin i <br /> Cobnty4 Ordinance-No.-1862 .-and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r 4Q CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name <br /> License �� , Q�13 Phone _4j."ZJfJ_ 1 <br /> i <br /> TYPE OF WORK (Check): NEW WELL /f� DEEPEN '/—/ RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION '/ I PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /pp 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 /> W <br /> Domestic/private Drilled Dia. of Well Casing IVI <br /> Domestic/public Driven Gauge of Casing gag A., <br /> Irrigation Gravel Pack Depth of Grout Seal .7��' <br /> Cathodic Protection � / Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State'Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j 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 of the well and notify 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 TO G OUTING AN A NAL IN CTIO <br /> SIGNED TITLE <br /> D W T' AN 'ON REVgM SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE / 1 <br /> ADDITIONAL COMMENTS: <br /> PHA I, 0I,1,Z0M INSPECTIONP E II / INAL INSPECTION <br /> INSPECTION BY ATE Com-- INSPECTION BY DAT <br /> E H 1426 Rev. 1 .74 <br />