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AN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OArQFFSICE USE`.'-, ' :1601 E. Hazelton Ave. <br /> Stockton, <br /> Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuecl,f,—, �-;?_4— <br /> C j (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 /> f County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> t S / <br /> JOB ADDRESS/LOCATION f �C 7"4_5"jga CENSUS TRACT <br /> . r <br /> Owner's Name Phone <br /> Address q,Vg i cityc <br /> Contractor's Name ¢;VLicense y Phone V6),2626 <br /> 1 � <br /> 41 <br /> r iTPE OF WORK (Check): NEW WELL '/? DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT­ /_7 <br /> Other. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOQL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> r Industrial i Cable Tool Dia.` of Well Excavation <br /> � r Domestic/private f Drilled Dia. of Well Casing <br /> i Domestic/public Driven Gauge of Casing <br /> I 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 INSTA�;LATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REP <br /> LACEMENT: State Work k Done . <br /> PUMP !REPAIR: / State Work DoneCA <br /> I <br /> j <br /> E&TRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure <br /> j <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 hem. efore putting the..well in use.. The above <br /> information s true to the best. kn edge n belef. I WILL CALL 'FOR A 'GROUT INSPECTION <br /> PRIOR UTING FINAL. <br /> SIGN D , TITLE2f, <br /> ( W P LAN ON ERSE SIDE i <br /> kllolr FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT BY DATE tS�L�� �0 i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f PHASE ixslxINAL INSPEC ION r <br /> INSPECTION BY DATE: INSPECTION. BY ZJ <br /> ,; ryE"H 1426 <br /> Rev. 3-74 U <br /> W:; � � - 1...74 9M "�w,-1 <br />