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r <br /> coo l* 4 Oil SAN JOAQUIN LOCAL HEALTH DISTRICT 0' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7,,7_ID. J� <br /> w <br /> TMS PERMIT EXPIRES I .YEAR FROM DATE ISSUED Date Issued <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 1-01 -- OtfO-VZ_ <br /> Owner's Name b# Phone <br /> Address City 5;26 <br /> i <br /> r <br /> Contractor's Name g License # -?xi Yhone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR I�Lh PUMP-REPLACEMENT f / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES :SPIT 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 A{ <br /> Domestic/public Driven `' Gauge of Casing <br /> CIAO <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 /> PUMP INSTALLATION: Contractor <br /> F Type of Pump H.P. low <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work' Done ,, 1�J : .� <br /> `IIlg) ts)ct v - rzo-A of$ 4% <br /> DESTRUCTION OF WELL: Well Diameter Afproximate Dph <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 /> 1 after completion of my work on a new well, I will furnish the San Joaquin Local. Health District <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 n wle ge n ief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO UT NG AND FINAL I TI <br /> r SIGNEDITLE <br /> RAW LO ON RE RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE `"gv <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROU PECTION PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> E H 1426 Rev. - I-74 -- - - - - <br />