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• SAN JOAQUIN LOCAL <br /> HEALTH <br /> E; Fopl i OFFICE USE: HEALTH DISTRICT E. Hazelton Ave:;-Stockton, Ca <br /> _f <br /> Telephone: <br /> (209) 466-6781 : <br /> APPLICATION FOR WELL CONSTRUCTION :OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Ap.plicatiorCis hereby made to the San Joaquin Local Health District foraermit toconstruct <br /> ' <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/LOCAATION - e2`f 7- r So-0 2— Y <br /> CENSUS TRACT <br /> Owner's Name j �' 4 J f C /�" tr*jj -(✓JV <br /> 0 Phone ( � <br /> Address- <br /> city , S <br /> Contractors Nam <br /> License #G;2� Phone g 7 <br /> TYPE OF WORK-.(Check): NEW WELL '/-7 DEEPENL/? RECONDITION /? DESTRUCTION f"j <br /> PUMP INSTALLATION / / PUMP REPAIR � PUMP REgLACEMENT /� <br /> Other / /% _ <br /> O y <br /> DISTANCE TO NEAREST: SEPTIC TANK Q <br /> -',.. SEWER LINES � PIT PRIVY <br /> SEWAGE DISPOSAL FIELDOTHER <br /> ` CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE '- PRIVATE DOMESTICfWELL' PUBLIC DOMESTIC WELL— <br /> IN ENDED USE TYPE OF WELL` CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. <br /> Domestic/private Dof Well Excavation <br /> rilled Dia. of Well Casing <br /> ,Domestic/public <br /> Driven— �� G$ <br /> Irrigation-, `� ugeJof Casing <br /> Gravel Pack Depth of Grout Seal <br /> RCathodic <br /> Protection'- I� — Rotary . Type of Grout r r <br /> Disposal. � . Other Other'.Information I <br /> __Geophysical �• <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump ? <br /> H.P. <br /> PUMP REPLACEMENT.' p <br /> // State Work Done •i� <br /> r <br />`PUNg'`REPAIR StAi--Work-Dori <br /> ES TRUCTION OF .WELL: <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distri <br /> ct <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 thea before puttingthe well in use.. The above <br /> information is true to the-best-of my ,knowledge and belief. I WILL' CALL FORA GROUT INSPECTION i <br /> PRIOR TO GROUTING AND F INSPECTION: i <br /> SIGNED <br /> TITLE <br /> (HitAW PLOT PLAN ON REVERSE SID ! <br /> PHASE I t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: DATE v <br /> PHASE II G S0 PHASE I F,1NAL <br /> INSPECTION BY ATE INSPECTION BY INSPECTION <br /> _ DATE yJ <br /> E H 1426 Rev. 1-74 <br />