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e� l uJq� <br /> ' SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR_;QFE CE USE: 160. 1E. Hazelton Ave. , Stockton, Calif. <br /> .`v. <br /> Telephone: <br /> �. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT E iRES l YEAR FROM DATE ISSUED Date Issued <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 acid the Rules and Regulations of the San -Joaquin Local Health District. <br /> i . <br /> E JOB ADDRESS/LOCATION __._._... ��.Q4A /I CENSUS TRACT <br /> . <br /> Owner's Name _ .. 5� o <br /> Phone <br /> l Address <br /> city . <br /> _ <br /> Contractor's Name <br /> _ � Licen,ae .# ' Ph <br /> one <br />:' TYPE OF WORK (Check) : NEW WELL -/? DEEPEN /?, RECONDITION /_ DESTRUCTION /_ <br /> PUMP INSTALLATION -.►fir PUMP REPAIR '/� - PUMP REPLACEMENT /T <br /> f - Other 1/% — <br /> DISTANCE TO NEAREST: SEPTICTTANK 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 _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toa1 Dia. of Well Excavation <br /> Domestic/private Drilled 1Dia. of Well- Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation_ € Gravel Pack-- Depth of Grout Seal . <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION; Wil~ Contractor <br /> Type .of Pump H.P. y. <br /> PUMP <br /> !E'1�f1'f <br /> . ,• / / State Work Done <br /> PM MPAIR: . . . <br /> / / State Work Done <br /> DE&TRUCTION OF. WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withfall 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, l 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-belt-of' . .kn ed belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO__GROUTING AND ALJIN CT ,�• <br /> SIGNE .. ITLE <br /> F (D ON , SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I .� <br /> APPLICATION ACCEPTED B DATE4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S FIN INSPECTION <br /> INSPECTION.BY SATE, INSPECTION•-BY DATE <br /> E N 1426 Rev. 1--74 i. `` ` - 1J7K 9M <br />