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Ca (IFF <br /> SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOF�t FILE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> iiieee Telephone: (209) 466•-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pal-mit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 axid nth Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONrps ,br CENSUS TRACT <br /> Owner's Name / Phone <br /> Address ..D, �J O City _ <br /> Contractor's Name License # Ai PiLl"Phone W-,--Ag7,e <br /> UP <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /-' RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR Z/ 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 � I <br /> Wi <br /> Domestic/private Drilled Dia. of Well Casing (,3 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ^Q <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contracto <br /> Type of Pump H.P. 14- 0 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP�REPAIR: /C� State Work Done ,E 00:1;1 �. <br /> MS TRUCTION 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 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 tie before putting the .well in use.. The above <br /> information is true to the-bes my w edge a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TING AND A FINAL E IO <br /> SIGNE TLE <br /> ( L T LAN ON SE SIDE) <br /> 40R REPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G S ECIO PHASE III FINAL INSPECTION <br /> INSPECTION BY V DATE INSPECTION BY DATE - -Zgg' <br /> 1 E H 1426 Rev. 1-74 f� 2M <br />