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r° SAN JOA UIN LOCA <br /> r Q L HEALTH DISTRICT' <br /> FOF�r VICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEjSSUED Date Issued — <br /> (Complete In Triplicate) t 7.3- Z FD-2-o <br /> ApPI#cgtion is hereby made to the San Joaquin Local. Health District :dor a permit to construct: 1 <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION See, qt,y � �y� � CENSUS TRACT <br /> " <br /> Owner's Name A!5 "-,o r _ <br /> Phone <br /> Address <br /> City <br /> Contractor's Name License # L 37xj Pkione y <br /> TYPE OF WORK (Check[) : NEW WELL /? DEEPEN /7 RECONDITION /? DESTRUCTION /7 <br /> / , <br /> PUMP INSTALLATION / / PUMP REPAIR. / PUMP REPLACEMENT � 1 <br /> Other <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 CONSTRICTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool. Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ` <br /> Irrigation Gauge of Cas ng <br /> Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> .;,_Disposal Other Other Information <br /> GeophysicalSurface Seal Installed $ I <br /> PUMP INSTALLATION: _ Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / IT State Work Done <br /> PTJM1' '.REPAIR: / State Work Done <br /> PES�TRUCTION OF WELL: Well Diameter <br /> Approximate Depth � <br /> Describe Material and Procedure - + <br /> r <br /> I hereby agree to comply th 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 an re3 f. I INSPECTION <br /> PRIOR U TNG AND FINAL INSPECTION, WILL CALL FOR A GROUT I ' <br /> SIGNED p. <br /> (DRA P O P O REVE E SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> -/? <br /> PHASE II GROUT INSPECTION `f PHASE III/FINAL INSPECTN <br /> I .�. <br /> INSPECTION BY DATE INSPECTION. BY r DATE r <br /> ryE H 1426 Rev. 1-74 <br />