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T <br /> C� lee,( SAN JOA UIN LOCAL HEALTH DISTRICT <br /> C <br /> FOE.OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S.r�pyp <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued :-.a 7 <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. 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> svveo60�� �4 � `l• <br /> JOB ADDRESS/LOCATION - -c 4d @ Q ;� �I r � CENSUS TRACT <br /> Owner's Name Phone <br /> Address Q, City . a 54 <br /> Contractor's Name .�,�v License #1 7 x: Phone ' <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /'7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ PUMP REPLACEMENT f7 <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 /> Domestic/public Driven Gauge of Casing ) <br /> _ A 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: Contractor <br /> Type of Pump " +a1 H.P. <br /> 4.1 <br /> PUMP REPLACEMENT L/ State Work Done <br /> PUMP ,REPAIR: State Work Done�f , f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hdreby 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 /> atter 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 ab:nve <br /> information is true to the•best-of my kn ed nd lief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO I G AND A FINAL INSPECT ON. <br /> SIGNED <br /> (DRAW P 0'T_PAN ON RE . RSE SIDE <br /> PHASE I U?DR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE �� } <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTION P S I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 r h/75 . 2M <br />