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SAN JOA UIN LOCAL <br /> - HEALTH HEALTH IDISTRICT <br /> FOE..OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued /-/1�7(, <br /> r sic t�),4=Y- -._t- (Complete In Triplicate) _ <br /> Application is hereby rr�ed`e �n <br /> 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 Joaquf <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> /741 is 75, <br /> JOB ADDRESS/LOCATION92 le2) .rC. 4 CENSUS TRACT <br /> - <br /> I Owner's Name r <br /> Phone <br /> 1,,Address ` <br /> _ City . <br /> ' <br /> Contractor's �-" <br /> for s Name License # k have �•7C;7Z <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/_7 RECONDITION /T DESTRUCTION f 7 <br /> PUMP. INSTALLATION / PUMP REPAIR PUMP REPLACEMENT f� <br /> Other, <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DONESTTrWELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing V <br /> Domestic/public - r _ .. �..� Driven Gauge of Casing <br /> Irrigation '" Gravel Pack Depth of Grout Seal n <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal ±�-' Other Other Information <br /> Geophysical <br /> Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type r.of Pump <br /> IHop. <br /> PUMP REPLACEMENT: / / i S tate Work Donee. .i <br /> PUMP 'REPAIR: State Work Done <br /> DESTRUCTION OF WELL:, �Wel1 Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all lawsarsd 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 /> PRIORinformation is true to-% A "'r -best of my.. o ed belief. T WILL CALL FOR A'GROUT INSPECTION. <br /> PRIOR TO GROUTING AND A FINAL INSPECTIO <br /> SIGNE - s • - - <br /> TLE <br /> 14 (D LAN ON RE SE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE •I <br /> APPLICATION ACCEPTED BY DATE ' /-/ 6 <br /> ADDITIONAL COMMENTS: t <br /> 'PHASE IT GROUT INSPECTION PHASE TIT FINAL INSPECTION <br /> j INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 1. A;r .,,, <br />