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r <br /> a,- o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FIC-' USE: 1601 E. Hazelton Ave. , Stockton, Calif, ct5 <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 /0 17.7 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /-to ep 40 J(� OfJos�� CENSUS TRACT <br /> Owner's Name plawa o Phone <br /> Address / D g`LSl / City <br /> Contractor's Name License # Ae-7X-�hone rV-7474 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN "/—/ RECONDITION /_/ DESTRUCTION /- _ <br /> PUMP INSTALLATION /,e/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINA; - 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 <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 t` H.P. / <br /> PUMP REPLACEMENT: / / State Work hone <br /> PUMP , PTi"fR: State Work Done <br /> DESTRUCTION 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 <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. m owledge e.lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT NG AND A FINAL INS N. <br /> SIGNED 1KTMT E <br /> /""(D RA14 I PY-0–VtLAN ON R FRSE SIDE) i <br /> OR DEPARTMENT USE ONLY 7� <br /> PHASE I <br /> APPLICATION ACCEPTED BYw 9DATE ��/,q�) <br /> ADDITIONAL COMMENTS: '� <br /> PHASE II GROUT INSPECTION PA&SE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /f 1y DATE /I - 1,V -77 <br /> E H 1426 Rev. - 1-74 n��7 2M <br />