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rSAN JOAQUIN LOCAL HEALTH DISTRICT \ <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br />' Telephone: (209) 466-6781 <br /> t a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _7iJ Z7 <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �a <br /> (Complete In Triplicate) <br /> l Application is hereby made t6 the Sari 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 /> j County Ordinance No. - 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� r� CENSUS TRACT <br /> Owner's Name 1( . G ® Phone <br /> Address . City <br /> Contractor's Name Ric At bug 4x License 7T_AN�Phonef <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/_/ RECONDITION DESTRUCTION /7 W <br /> PUMP 'INST�ATION PUMP REPAIR / / PUMP REPLACEMENT I^T � <br /> Other / / Q <br /> DISTANCE TO NEAREST: SEPTICSTANK f� _t- SEWER LINE /E0 PIT PRIVY •--- <br /> SEWAGEIDISPOS L IELD r CESSPOOL/SEEPAGE PIT/ ebBTHER"'!� <br /> PROPERTY LZN 24RIVATE DOMESTIC WELL"__..+PUBLIC- DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> A--Domestic/private i11ed Dia. of Well Casing <br /> Domestic/public t Driven Gauge of Casing 1_2- <br /> Irrigation 1 Gravel Pack Depth of Grout Seal " _4z-40, �0- <br /> f Cathodic Protection ` Rotary Type of Grout <br /> Disposal 1 Other Other Information - <br /> Geophysical _ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor /?� J�'l d 1' <br /> Type of Pump o` H.P, <br /> k <br /> PUMP REPLACEMENT: / / I,State Work Done <br /> PUMP .REPAIR: / / !State Work Done <br /> T <br /> DESTRUCTION 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 regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San,,,,;Toaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in use.. . Ttie above <br /> information is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPEC <br /> SIGNED TITLE <br /> ! Y-MM PL T P ON REVERSE 'SI-DE) <br /> x FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' <br /> APPLICATION ACCEPTED BY ` DATE 8 <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY , DATE INSPECTION BY DATE <br /> b/7.7 2M <br /> E. E H 1426 Rev. - l-74 f ----- - <br />