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6 <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> o � � <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. P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Data Issued <br /> (Complete In Triplicate) / <br /> Application is hereby made to the San Joaquin Local Health District for a permit to const uct <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 oftheSan Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � f,l 3 rr/ a t ,c 7-� C CENSUS TRACT <br /> Owner's Name 4y" r rear ,� <br /> Phone <br /> A'y �. r e•- r 7 f <br /> Address . d !�, City ` - "�, „ <br /> ;... j: ��_.,� �! .� gp #�- f6,21 <br /> Contractor's Name '� License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ PUMP REPLACEMENT <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 <br /> Domestic/private ,. Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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 /> Type of Pump cfw � F�- �, _...,...__, ..—. H.P. <br /> - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> i <br /> DESJRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> 4 <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 f,.,my nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR TO _RQUTING AND 4 FIN T ®N <br /> SIGNED �6' <br /> ..: TITLE �' a <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �+,,Q DATE : .-J77 <br /> E H 1426 ,Rev. 1--74 - 1f77 2M _ <br />