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/C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> AF Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> � <br /> J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> S .�,Kt; cc�.4 t/ (Complete 1n Triplicate) F - A) : ('83--1 (C�-0 <br /> � <br />{ Application is hereby made to the San Joaquin Local Health District for a permit to const uct <br /> is made in compliance with San Joaquin <br /> and/or install the work herein described. This application <br /> County Ordinance No. 1862• and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION--4, 1 .-'�t�, mss a G wl�S CENSUS TRACT <br /> Jam / <br /> ra <br /> Owner's Name J' Phone <br /> Address <br /> aif City <br /> F _11hoiie 76 <br />' Contractor's Name License # <br /> �i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION '/ / -PUMP REPAIR /X/ PUMP REPLACEMENT <br /> ' Other 1_7 <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 4 CONSTRUCTION SPECIFICATIONS <br /> Industrial ,.Cable Tool Dia. of.Well Excavation <br /> �X '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 /> Geophysical Surface Seal Installed By: <br /> H <br /> PUMP INSTALLATION: Contractor <br /> t .P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> t . <br /> PUMP .REPAIR: /)(/ State Work Done 4e- <br /> DESTRUCTION OF WELL: Well Diameter Approrimatie Depth�' <br /> Describe Material and,Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin LocalFHdalth 'District <br /> and the State of Califorriia' pertainirig °td or regulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new we11, 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 tojAFINAL <br /> e best kn wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> C PRIOR TO GROUTING AND 0 <br /> f , <br /> SIGNED . _ TITLE <br /> W . Lfi. PLAN ON E R-SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 •�` - <br /> P' <br />