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�O„ /,v°4GJ SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOR1 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. --QaQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued'S� <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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION4-6a C9NSUS TRACT <br /> Owners Name C4 Phone <br /> Address c`/.(' ✓ City " <br /> Contractor's Name Li492 —0cense l %4 hone - <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION 17 DESTRUCTION /-7PUMP INSTALLATION / / PUMP REPAIR -7 PUMP REPLACEMENT /-7 <br /> Other /7 <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 /> �- C Domestic/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 Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractoru/ , <br /> Type of Pump ,� <br /> H.P. <br /> PUMP REPLACEMENT: / / State. Work Done <br /> PUMP ,.REPAIR: State Work Done <br /> ES•TRUCTION 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 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 GROUTZW AND A FINAL INS N, <br /> SIGNED IT <br /> (DRA L T P REVER <br /> FOR DEPARTMENT USE ONLY <br /> PRISE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: C.3 "--" <br /> PHASE II GROUT INSPECTION PHASE III FI AL INSPECTION <br /> 'NSPECTION BY DATE INSPECTION BY ', DATE <br /> 3//-7,!� <br /> q <br /> ' H 3.426 Rev. 1-74 1-74 2M <br />