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l <br /> C6rrti A. � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH;OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> a-. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�p <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 permit to construct <br /> and/or install, the work herein described. This application is made in compliance with San Joaquinl <br /> ` County Ordinance No. 1862 and the Rules and Regulations of the San, Joaquin Local Health District. ` <br /> JOB ADDRESS/LOCATION .� b__� a ILD�G � CENSUS TRACT <br /> Owners Name ams ��,�`� - �,7�_eEc� Phone , <br /> Address C� �1 u,rQ�o�, City , <br /> Contractor's Name elf License #12Phone v <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN '/P RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION-/ f PUMP REPAIR'Z PUMP REPLACEMENT f-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 U� <br /> Industrial i Cable Tool Dia. of Well Excavation p <br /> Domestic/private s Drilled Dia. of Well Casing <br /> Domestic/public s Driven Gauge of Casing p <br /> Irrigation j1 Gravel Pack Depth .-of Grout Seal . <br /> Cathodic Protection ;1 Rotary Type of Grout <br /> Disposal Other Other Information <br /> j Geophysical Surface Seal Installed By: l <br /> PUMP,INSTALLATION- Contractor <br /> s Type of Pump H.P. L <br /> PUMP REPLACEMENT: . / / State Work' Done 4 <br /> PUMP �REPAIR: State WorkDane r <br /> I 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 <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I 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 there before putting-the .well. in.use.... .The above <br />[ information is true to the-best Tf. my know ge nd belief. I WILL CALL FOR A GROUT INSPECTION <br />! PRIOR TO GR UTING 'AND A FINAL IN N. , <br /> SIGNED / TITLE <br /> 1 <br /> 11 "RAW PWT PLAN VERSE SIDE <br /> FOR DEPARTMENT USE ONLY . <br /> PHASE I <br /> APPLICATION" ACCEPTED BY DATE , <br /> ADDITIONAL- COMMENTS: Ii <br /> r PHASE II GROUT 'IN PECTION PHASE II INAL PECT <br /> INSPECTION BY DATE INSPECTION BY A <br /> E H 1426 heir_ 1-74 11/75 2M <br />