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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone : . (209) 466-6781 <br /> L APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Ze /05� <br /> THIS ,PERMIT EXPIRES l 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 Joaquin <br /> County Ordinance No. 1862 and the- Rules and Regulations of ,the San Joaquin Local Health District. <br /> JOB ADDESS/ @tflft CENSUS TRACT <br /> Owner's Name !� Phone <br /> Address l City <br /> i Contraetor's_,Name. .L:icense-�{ �fff-P-hone• •1 9) <br /> TYPE OF WORK (Check) : NEW WELL A/T DEEPEN / /• ' RECONDITION, % /„ DESTRUCTION 9.7 _ <br /> PUMP INSTALLATION IV PUMP REPAIR /—/ PUMP REPLACEMENT Other <br /> / / N <br /> f <br /> kDISTANCE I'TO 'NEAREST: SEPTIC TANK 2 Q� SEWER LINES- PIT PRIVY <br /> SEWAGE DISPOSAL, YIELD r-- CESSPOOL/SEEPAGE PIT /� OTHER <br /> PROPERTY LINE RIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL R <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> Domestic/private �t Drilled Dia. of Well Casing 1te-A <br /> Domestic/public —f'- Driven Gauge of Casing V"o <br /> 3 IrrigationI Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r <br /> Disposal Other ; Other Information <br /> iGeophysical Surface Seal Installed By: 6 <br /> PUMP INSTALLATION: ContractorIF A fZ C4►� , S <br /> ' Type of PumpVii` 3 H.P. <br /> fPUMP REPLACEMENT: / / State Work Done ' <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �_ Appro mate 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 dr regulating we1Z-sconstruction.j� Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish .th_e San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the: welitin 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED d PLAON EVERSE�SIDE <br />` FOR DE ARTMENT 'USE ONLY,,,,` t <br /> PHASE I <br /> APPLICATIO ' <br /> N ACCEPTED BY ,.f'� � DATE ?-/l9' 7 <br /> ADDITIONAL COMMENTS: <br /> P <br /> ILAM II GROUT INSPECTION PHASE III/FINAL INSPECT ON <br /> INSPECTION BY DATEINSPECTION BY DATE <br /> 0177 _ 2m <br /> E H 1426 Rev. • 1. 74 , <br />