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S JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE.. OFFICE USE: 160]' ..) Hazelton Ave. , Stockton, Cal` <br /> elephone: (209) 466-6781 - p. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES l YEAR FROM- DATE ISSUED Date Issued p_ r <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct <br /> and/or .iinstall the work herein described. This application "is made in compliance with San Joaquin <br /> County Ordinance No. 186 and/ the Rules,,a5d Regulations of the Sao. Joaquin Local Health District. <br /> E JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name " Phone -`1177,!67?01 <br /> Address ` City <br /> Contractor's Name <br /> /ViO License #-r12__S1irL9_nPhone <br /> TYPE OF WORK (Check) : NEW`WELL 'ff DEEPEN '/—/ RECONDITION /_7 DESTRUCTION I_7 <br /> PUMP INSTALLATION I PUMP REPAIR / I . PUMP REPLACEMENT /7 <br /> Other / I <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 WELD,'' <br /> 'INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation _ _lam <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge, of Casing <br /> "Irrigation Gravel Pack Depth of Grout Seal "c " e <br /> Cathodic Protection 2< Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractorve�/�/ <br /> Type of Pump Z H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> i <br /> PUMP .REPAIR: /_7 State Work Done <br /> I <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 I <br /> and the State of California pertaining to or regulating well 'canstruction. 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 knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT*G AN&A FIN INSP ION, <br /> SIGNED U.A 14 611heliClIvTITLE <br /> PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT �, — <br /> r' <br /> ADDITIONAL COMMENTS: if <br /> s P I G UT INSPECTION PHASE /FINAL INSPEC ION <br /> INSPECTION BY X<Q DATE 7/ G INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 ;376 2M <br />