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C,&k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR rOFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V, 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 6-/9,-7,5' <br /> ii (Complete in Triplicate) <br /> Applicationits hereby made to the Sat: 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 /> A �C9_� <br /> JOB ADDRESS/LOCAtO dm0� k $'rye A.of"#4e0",ACENSUS TRACT <br /> ; <br /> Owner's Name Phone <br /> Address 1 e'r _ 00 City <br /> Contractor's Name c4r License # / 23-�Phone �Y <br /> TYPE OF WORK. (Check): NEW WELL /7 DEEPEN '/-7 RECONDITION /_� DESTRUCTION /-7 <br /> ' PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY c� <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT OTHER ©� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> s Cathodic Protection Rotary Type of Grout .� <br /> ` <br /> Disposal , Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r$ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ;REPAIR:1i /_7 State Work Done <br /> E&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 <br /> and the State of California pertaining to or regulati.ng, 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 u,)wledae an elief. I WILL -CALL FOR A `GROUT INSPECTION <br /> PRIOR TO—GROUTING AND A FINAL INSPEroTrQN. <br /> SIGNED ortTLE <br /> (DW TwT LAN ON REV SE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE --' -� � <br /> ADDITIONAL COMMENTS: P, <br /> PHASE II GR INSPE ON PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> st 1E H 1426 Rev. I-74 <br />