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) <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT - - <br /> FOBrOFFTCE 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 2. �. <br /> (Complete In Triplicate) l g,p t(&0 o.z_ <br /> Application is hereby wade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the -work herein described. This application 1s made in compliance with San Joaquin <br /> County Ordinance No.'.,1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION' CENSUS TRACT <br /> Owner's Namew s i <br /> I Phone--7- <br /> Address <br /> hone-- --7---- <br /> Address <br /> Cit ,I^ <br /> Contractor'e. Na ��_` J <br /> License / hone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN'/7 RECONDITION /_7 DESTRUCTION /7 <br />' PUMP INSTALLATION )g PUMP REPAIR /7 PUMP REPLACEMENT %f <br /> Other' / / <br /> DISTANCE TO NEAREST: SEPTIC' TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGEEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL'-- - PUBLIC DOMESTIC WELL <br /> INTENDED USE PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial TYr. Cable Tool Dia. of Well Excavation <br /> Drd <br /> = . Domestic/private �. "- T4ille_ r:. <br /> Dia: of Well 'Casing � <br /> - Domestic/public Driven Gauge of Casing I <br /> � e 'Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal x Other Other Information.... <br /> Geophysical Surface Seal Installed By: i <br /> PUMP INSTALLATION; Contractor >/ <br /> Type of Pump ✓ �ilrr� <br /> H.P. <br /> State Work Done fa-A-jajell <br /> PUMP �REPAIR: <br /> 17 ° State Work Done <br /> E&TRUCTION <br /> � OF WELL: Well Diameter- <br /> Describe Material and Procedure e <br /> I hereby agree to comply with`. all laws and regulations of the San Joaquin Local Health District f <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS' <br /> after completion of my work oa 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 TOG ND NG AFINAL NSPECIT' <br /> SIGNER .� _ ITLE <br /> PLOT i;AN ON REURSE SIDE �S <br /> PHASE I <br /> FOR-DEPARTMENT USE ONLY <br /> APP LOCATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: -4-'.a_ -4 Aa=.;� �,Z, <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTT N <br /> 'INSPECTION BY DATE INSPECTION BY DATE <br />` E H 1426 Rev. 1-74 <br /> 1_-7/. -11. <br />