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d� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OF�USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No;7- <br /> j� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applicati n 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 /> County Ordinance No. 1862 and the u s and Re ulations of the San Joaquin Local Health District. <br /> JOB ADORES G� � <br /> ADDRESS/LOCATION � S CENSUS TRACT <br /> Owner's Name H k m Phone <br /> Addressd.� 3�Y City cf'Jri -` <br /> Contractor's Name , License # /Y9-; Phone y-- e 7g <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION /)c/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / T� <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 T <br /> Domestic/public Driven Gauge of Casing <br /> )C Irrigation Gravel Pack Depth of Grout Seal _ <br /> Cathodic Protection Rotary Type of Grout C� <br /> Disposal Other Other- Information /v <br /> Geophysical Surface Seal Installed By: p <br /> PUMP INSTALLATION: Contractor <br /> Type o f Pump !" ,a H.P. zX <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .f4;PX;R_._ /x/ State Work Done <br /> DESTRUCTION OF WELL: Well DiameterApproximate-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 <br /> WELL DRILLERS REPORT of the well and notify them before puttingthewell in use. The above <br /> information is true to the best of my�kno+wl,ed e�an$belie f. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ITLE <br /> JER <br /> W T P ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /D DATE <br /> ADDITIONAL COMMENTS: " <br /> PHASE II GROUT INSPECTION P SE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ��j <br /> E H 1426 Rev. - l-74 <br />