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" Ass SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFr19rrTO'E USE: 1601 E. Hazelton Ave. , Stockton, Calif. �+ <br /> - Telephone : (209) 466-6781 ��13 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � ll <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�4 1�2f_/y <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 incompliance with. San Joaquin <br /> County Ordinance No. .1862 and the Ru les�and;rRegulations of the San. Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . _ � # r4 CENSUS TRACT tb(2a 02-n--o <br /> Owner's Name 01 0 owv Phone <br /> Address !? City <br /> r � <br /> Contractor's Name } License # 1-3-71rPhone �y <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR /`!/ 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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ( . <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> e Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed _By_:__ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: state Work Donep,�� � � G�,._,.,yr„g6 - Y �►� . � ia�r r� <br /> V <br /> DESTRUCTION 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 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 of4RA <br /> d an lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING AND A FINAL INS <br /> SIGNED ITLE <br /> P AN ON R ERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY& DATEj- <br /> 6"77 2M <br /> E H 1.426 Rev. - l-74 - <br />