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--E POW SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ren a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �`17 <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 AQ �i CENSUS TRACT <br /> Owner's Name -77 7 nw ` <br /> Phone <br /> Address City ., <br /> Contractor's Name License # f vj"`Phone <br /> TYPE OF WORK (Check): NEW WEL.L1 / DEEPEN /? RECONDITION /? DESTRUCTION _r <br /> k <br /> PUMP INSTALLATION / J PUMP REPAIR f4— PUMP REPLACEMENT U <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ~ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q1`. <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 /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Geophysical Other Other Information <br /> Surface Seal Installed BY _ W <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. j . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /W/ State Work Done <br /> DESjLUCTION OF WELL: Well Diameter <br /> -- 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 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 know a and-b lief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GR AND A FINAL INSPECT I <br /> SIGNED • TLE <br /> (DRAW P ON RSE SIDE <br /> PHASE I <br /> DEPARTMENT USE ONLY <br /> .. <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1 f,�7: F "2K <br />