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C6 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF2;OFFICE USE: V1601 E. Hazelton' Ave. , Stockton, Calif. <br /> +' Telephone (209) -466-6781 <br /> a' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRESA YEAR FROM DATE ISSUED Date Issued <br /> t (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..Regulati'one of ,the an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1l o wed0111v, A+CENSUS TRACT <br /> t <br /> Owner s Name ,.- ~` L,G ' -r Phone E d e}� <br /> Address a'L. -r'- y ' 40 0 f\... City , . <br /> Contractor's Name License '_—� Phoned <br /> TYPE OF WORK (Check); NEW WELL L 7 DEEPEN '/- RECONDITION -/_7 DESTRUCTION,] <br /> PUMP INSTALLATION j5;7 PUMP REPAIR/7 PUMP REPLACEMENT /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 G� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> Industrial Cable Tool Dia. of Well Excavation <br />— Domestic/private Drilled Dia. of Well Casing. ' <br /> Domestic/public Driven F Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary � ' ,Type of Grout ' <br /> Disposal Other r ; Other Information ' <br /> Geophysical Surface Seal Installed1i <br /> PU)T' INSTALLATION: Contractor . <br /> is Type of Pump - H.P. / <br /> PUMP Mss /Jc/ State Work Done <br /> PUMP°.REPAIR / /:State'Work Dane <br /> PESjRUCTION OF WILL: 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 /> 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 .of my.know dge and ellef. I WILL CALL OR A GROUT INSPECTION <br /> PRIOR TO NG AND A INAL INSPECTIO . <br /> (DRAW REV ..SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' �� s <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPIECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Y INSPECTION BY k DATE <br /> E H 1426 Rev.. 1-74 f 475 2m <br />