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- ro h ` ' SAN JOAQUIN LOCAL I•IEALTH DISTRICT ` <br /> FO$�OF ICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 p <br /> . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No �/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9~�l� <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 �d o a d„ � _ CENSUS TRACT <br /> Owner's Name , _ -�- Phone M -jze.7,1 <br /> Address <br /> City <br /> Contractor's Name ,..� License #/j, 'Phone �_7,, <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION f7PUMP INSTALLATION / / PUMP REPAIR &T/—PUMP REPLACEMENT / f <br /> Other /% — <br /> u- ' f oGt 4rgy' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE 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 /> _.2iI <br /> ._ 8 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal installed B : <br /> PUMP INSTALLATION: Contractor 'N', x/ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done �— <br /> PUMP :REPAIR: .7 State Work Done / d L � <br /> ES•TRUCTION 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 fi <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-beat of my knowledge and ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR To qpkUTING AND A FINAL INSPECTIO <br /> SIGNED TLE <br /> (DRAW PL9T P N REV ft SIDE) <br /> FOIR DEPARTMENT USE ONLY <br /> PHASE I y <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION DATE <br /> E H 1426 Rev. 1-74 ' <br /> _ 1-74 2 ` <br />