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Q�E- U <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:O1601 E. Hazelton Ave. , Stockton,. 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 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 -JoaquinLocal Health District. <br /> A) , C+16. "A` 44 ., ��r � C7 <br /> JOB ADDRESS/LOCATION oc.. ` . „� CENSUS TRACT -_ <br /> t <br /> Owner's' Name j= . Phone <br /> Address 4 6 72a 1 � L4,0mve City <br /> k Contractor's Name' 4 License ' hone ), 212-i� <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN '/-7 RECONDITION /7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> f 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 /> 4 (INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ )e,_ Irrigation Gravel Pack Depth of Grout Seal <br /> . Cathodic Protection Rotary Type of Grout.' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed .B <br /> PUMP INSTALLATIONa Contractor, � t <br /> Type of Pump r� „rj "" ". ' �•'_ r H.P. <br /> s <br /> PUMP REPLACEMENT: . / / State Work Done _ <br /> PUMP `REPAIR: State Work Done Pro <br /> I iSiRUCTION OF WELL: Well Diameter Approximate Depth <br /> ll 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 knowledge-and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO ROUTING AND A FINAL INSPE 0 <br /> SIGNED ITLE ; <br /> PLOT PL ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' 7111zE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASEOX III AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATL' <br /> R 'F1 1L94 94 Dai. 1-7A r. 4/75 �+'j <br />