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L � SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> FOE.OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 -6781 -� �`,� <br /> APP LCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> �� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �Z9 <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 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 CENSUS TRACT <br /> Owner's Namey> Phone <br /> Address City <br /> I Tz-)�ea2z,-- <br /> Contractor's Nam License k/*47A,�hone cot. 7,C76 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / f RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/5i/--PUMP REPLACEMENT /7 <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 V <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> )c 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 47Ad Q, Cl- <br /> Type <br /> Type of Pump 'a . H.P. <br /> PUMP REPLACEMENT: /7/ State Work Done <br /> PUMP REPAIR: />[/ State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter 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 pe��a.ining 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 of my kn6wledg' land-Velief. I WILL CALL FOR A GROUT INSPECTION <br /> _ .e <br /> PRIOR TO GROUTING AND A FINAL IN�.PECT N. � <br /> SIGNED / "rr' �► ,,, ITLEri- <br /> (D I,AIq' ON RE TLSE SIDE) <br /> 04 <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE N INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - / <br /> 1177 . _ 2M <br /> -E H. 1426 Rev. 1-74 <br />