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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r FOF OFFOC_ USE: i; 1601 E. Hazelton Ave. , Stockton, Calif. - <br /> Telephone: (209) 466-6781 Fr <br /> ;APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7 IS�� <br /> ,i THIS PERMIT EXPIRES 1 YEAR, FROM DATE .ISSUEDDate Issued 11-W-7117 <br /> n <br /> (Complete In; Triplicate) <br /> N <br /> Application is her 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 <br /> CENSUS TRACT <br />`I. Owner's Name ' <br /> Phone <br /> Address CO naa, / .E� N lbw 521& -' <br /> la, city C <br /> Contractor's Name <br /> ,.v License # /f37X_ Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / ITL RECONDITION DESTRUCTION /- _ <br /> PUMP INSTALLATION /�/ PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> it <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 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 /> y Domestic/private Drilled \' <br /> Dia. of Well Casing <br /> Domestic <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> n <br /> Cathodic� Protection Rotary Type of Grout r <br /> Disposal Other Other Information <br /> Geophysical `�--�-- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: .,f F <br /> Contractor <br /> ` Type of Pump ur' ! H.P. a2 f <br /> _ <br /> PUMP REPLACEMENT: <br /> State Work Done � <br /> 3i <br /> PUMP ` R: /_17 State Work Done / <br /> WCC'- <br /> DESTRUCTION OF WELL; Well Diameter # <br /> f. <br /> Describe Material and Procedure Approximate Depth <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. of. m knowled <br /> (,e," belief, I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO G 0 TING AND A FINAL INSPE IO . <br /> SIGNED r _ ITLE <br /> D,RAL PLOT LAN ON RR SE SIDE) r <br /> j <br /> PHASE I :i FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY s _ <br /> ADDITIONAL COMMENTS: DATE <br /> I. 1 <br /> PHASE II GROUT INSPECTION PHAS I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE '7 <br /> li <br /> E H 1426 Rev. - I-74 f <br />