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SAN JOAQUIN LOCAL HEALTH DISTRICT 4 II <br /> FOR OFFICE..U. 1641 .E. Hazelton Ave. , Stockton; alif. <br /> I ` C` Telephone: (209) 466-&781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT \Permit No. 7r =�3 d <br /> THIS PERMIT EXPIRES .1 YEAR -FROM DATE ISSUEDDate.!;Ilssued ��'7d <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permiti.t. construct <br /> and/or .install the work herein described. This application is made- in compliance' \. San Joaquin <br /> County Ordinance No. 1862 and--theles a Regulations of the San Joaquin Local.;Health District. <br /> JOB ADDRESS/LOCATIONACV 3 a 6 .I <br /> e w 14tAA <br /> CENSUS. TRk CT , <br /> Owner's Name Phone <br /> Address '` / <br /> Ir - City' - , <br /> Contractor's Name A/y & 9,-A A ,,r License �k �Phone <br /> TYPE OF WORK (Check) : NEW WELL ',O' DEEPEN I_I RECONDITION / DESTRUCTION /71 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKIf <br /> ,�_ B -� SEWER LINES � PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD ZaL CESSPOOL/SEEPAGE PIT OTHER �[ <br /> PROPERTY LINE/Q PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> c INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal M <br /> Cathodic Protection Rotary Type of Grout rs� <br /> Disposal Other Other Information IM <br /> Geophysical <br /> Sur'Face Seal Installed B cl <br />` ..PtMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> H.P.M. <br /> a <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> PUMP REPAIR: <br /> State Work Dane <br /> s iryowin.y ��� I� <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> Ak <br /> IM E <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> after comple <br /> and the State of California pertaining to or regulating sell--Construction. Within!IFIFTEEN DAYS <br /> tion of my work on a new well, I will`furnish the San Joaquin Local Health District a r <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe- well in use.... The above <br /> information is true to the best of my knowledge -and belief. I .WILL CA L, FOR A GROUT INSPECTI N <br /> PRIOR TO GROUTING ANiD A FINAL INSPECTION. ` - <br /> SIGNED <br /> TITi , ;F <br /> (DRAW PLOT PLAN ON REVERSE SID. ) ` II <br /> PHASE I FOR DEPARTMENT USE ONLY IE <br /> APPLICATION ACCEPTED BY DATE .? 7 <br /> ADDITIONAL COMMENTS: <br /> P S II ROUT INSPECTIO <br /> INSPECTION $Y P II/ INAL'. INSPECTION <br /> DATE f INSPECTION BY --_ DATE IM 7Ae <br /> , <br /> E H 1426 Rev. • 1-74 2y <br />