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co pp�o/f, / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE. (/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <br /> - (Complete In Triplicate) deP- (�kv'0 L- <br /> Application 'is hereby made to the San. JoaquinLocal 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 TRACT <br /> Owner's name.. ,c �iQ I''i .a Qom_ Phone <br /> k r.� <br /> k Address f°'�® � t`�j d-�+ ��.� city , <br /> Contractor's Name License # �Phone (� � •� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN"'/—/ RECONDITION /_/ DESTRUCTiON /-7 <br /> PUMP INSTALLATION / / PUMP -REPAIR -Y/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> � . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE 'PIT OTHER <br /> ' PROPERTY LINE -PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ki 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 Other Other Information <br /> GeophysicalSurface Seal Installed-By: . <br /> 'PUMP INSTALLATION: Contractor "3 <br /> Type of Pump H.P. c1 <br /> PUMP REPLACEMENT: / / State Work Done — <br /> PUMP -REPAIR: / State Work Done a, <br /> DES-TRUCTION OF WELL: Well Diameter i 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 IDAYS <br /> after completion of my work on a new well, I will furnish 'the San Joaquin .Local Health -District a <br /> r WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> �. information is true to the best ofr­my nowledge and belief. I WILL CALL FOR- A GROUT INSPECTION. <br /> PRIOR TO GROUTING AND A FI AIM IO <br /> SIGNED TLE <br /> D PL T' PLAN o!kloQN ERSE SIDE) ,; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE J--.7 - <br /> P - <br /> ADDITIONAL COMMENTS.:. , ;_• <br /> PHASE II GROUT INSPECTION PHASE III/FINAL-I­INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ;ZZ 2 <br /> 6 2M <br /> E H 1426 Rev. 1--74 <br /> /7 <br />