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l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i1F OF�E USE: 1601 E. Hazelton Ave. , Stockton`, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No �/(� Q <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED r Date Issued 9 <br /> (Complete In- Triplicate) <br /> Application is hereby made t6 the San Joaquin Local Health District for a permit to construct; <br /> and/or, install the work here n, described, This application is made in compliance with SanxJoaquin <br /> County Ordinance No. 1862 and the Rules and -Regulations of the -San Joaquin Local Health District. <br /> JOB ADDRESS/1,6CATION �) �1 ' CENSUS TRACT <br /> E Owner's Name II i <br /> k � Phone <br /> Address Cit y �. • <br /> Contractor's Name <br /> License # 1AS WPhone <br /> TYPE OF OF WORK (Check) : NEW WELL /._/ DEEPEN / / RECONDITION / / DESTRUCTION ' <br /> PUMP INSTALLATION / I PUMP REPAIR /tc/ PUMP REPLACEMENT f7 <br /> Other !/ / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C1 <br /> E SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> i CONSTRUCTION SPECIFICATIONS ¢, <br /> Industrial Cable Tool Dia., of Well. Excavation <br /> Domestic : <br /> /Private Drilled Dia, of Well Casing c <br /> 4 Domestic/public Dri._v_en -Gau e of _Casio f <br /> Irrigation - �, x g g - - - G <br /> g Gravel Pack, Depth of Grout Seal :+ <br /> Cathodic Protection Rotary Type of Grout <br /> D14osal ` � r ! Other Other Information <br /> Geophysical Surface Seal` Installed II �j <br /> MP INST� _- <br /> A.LLATION: Contractorm � <br /> Type d'f Pump a 'i,�/ H.P. ' y <br /> PUMP REPLACEMENT: I �. �1 <br /> / / State Work Done <br /> PUMP REPAIR: /�/ State Work Done y- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth I <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 <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 owled an elief. 'I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OU ING AND A FINAL INSPE T N. ' x <br /> SIGNED - ITLE <br /> i RAGS PLO P1-AN ON RE E SIDE) <br /> I! <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> � V <br /> APPLICATION ACCEPTED BY- DATE <br /> .. , .�._�w.>. <br /> ADDITIONAL COMMENTS � ----- <br /> PHASE II GRO.T IN _PECT,l.ON.. - ^.-PHAS.E,_. .I.I%.EINAL.w SPECTION� ? <br /> INSPECTION BY` DATE INSPECTION BY DATE <br />`"-j-_E -H I-426 Rev- 1-74 6/77 Ou / <br />