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_ v /1601 <br /> 6SAN JOAQUIN LOCAL HEALTH DISTRICT - -- <br /> FORiOFFICE USE: E. Hazelton Ave. , Stockton, Calif, <br /> I 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=12_--7S'_ <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�L Ordinance.,.No._1862 and the Rules and Regulations of the San Joaquin Local Health District.� :s_,4-c`,a"r,,..i,��7�T^ 2d,•^ <br /> JOB ADDRESS/LOCATION CENSUS TRACT f0 !3-150_02 <br /> Owner's Name Phone 3 <br /> Address 3 Q 0 97 City � <br /> Contractor's Name ,,C.� .�, � / License # Phone <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN I-7 RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICfTANK SEWER LINES PIT PRIVY <br /> SEWAGE�DISPOSAL FIELD Y CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC <br /> INTENDED USE WELL PUBLIC DOMESTIC WELL <br /> TYPE OF WELL„ q <br /> ' CONSTRUCTION SPECIFICATIONS <br /> Industrial ,_.. Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of -Well Casing p <br /> Domestic/public t <br /> Driven Gau e,of Casin <br /> g <br /> GravelPa _k Depthof Grout Seal - - <br /> Cathodic Protection_, Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical ^,�.� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor z,G�� <br /> Type f Pump f H.P. j <br /> :.i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: State Work Done L.l .. .e <br /> ES:TRUCTION OF WELL: Well Diameter <br /> 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 Arue to the-best-of myknowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROU D ;A FINAL INSPECTION. <br /> SIGNED I � TITLE <br /> (DRAW PLOT PL'AN'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY F l <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT NSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE. INSPECTION- BYf;% DATE ZI <br /> I -E H 1426 Rev. 1-74 <br />