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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOR.OFFACE USE: 1601 .E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PELT Permit No. ;�06/0 <br /> l � ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued <br /> r (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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , � � � ��,� - CENSUS TRACT <br /> Owner i s Name Phone <br /> Address d dit � Cityd `rJ+" <br /> Contractor's Name ' License. l Phone S4 <br /> Contractor's <br /> TYPE OF WORK (Check) : NEW WELL '/-7 DEtPEN. /� RECONDITION %f DESTRUCTION I T <br /> PUMP INSTALLATION"/ / PUMP REPAIR PUMP REPLACEMENT -7 <br /> Other' /_7 <br /> {' DISTANCE TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> k 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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> CathodicProtec_ti_ on Rotary Type of Grout ' }� <br /> --_..;,_Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed 'By: <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump _ - C/ H.P. � . <br /> PUMP REPLACEMENT:'. / / State Work Done .-,,--..-t <br /> PUMP .REPAIR: �/ / State Work Done <br /> F T_ � <br /> DES TLLUCTION 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 Isocal Health District <br /> rand 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 /> r WELL DRILLERS REPORT of the well and notify them before utting.the..well. in use.... The above <br /> information is .true to- the-b�est.of. my know ge a d elie I W �L CALL FORA GROUT INSPECTION <br /> PRIOR TO G NG ANDA PIN [SPE <br /> SIGNED <br /> (DRAW IAT LAN ON REVERSE iE7 <br /> L MR DEPARTMENT USE ONLY <br /> PHASE 1 . <br /> APPLICATION ACCEPTED BY ? DATES <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASIr III FINAL INSPECTION <br /> { INSPECTION BY DATE INSPECTION BY DATE rp'•/'3 '-) _ <br /> E H 1426 Rev. 1-74 475 2M <br />