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SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FOPx:OFFICE USE: 1601 E. Hazelton Ave:, Stockton, Calif. - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��- }6 �O <br /> k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 9-4- <br /> (Complete <br /> -4-(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. 3862 and the es and Regula ons of Che San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT <br /> Owner's Name Phone ' <br /> Address City <br /> E <br />€ LiS ;?Phone V^9 ; <br /> contractor's Name cense -- , <br /> TYPE OF WORK (Check): NEW-WELL /� DEEPEN -/? RECONDITION /? DESTRUCTION T"T <br /> PUMP INSTALLATION REPAIR'/ PUMP REPLAC 17, <br /> Other / / i <br /> DISTANCE TO NEAREST: SEPTIC TANK 5 R LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OT R <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL'-- PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> F Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing — - - <br /> - Irrigation Gravel Pack Depth of Grout Seal .477 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other : Other Information'_ <br /> Geophysical Surface Seal Installed By : <br /> ;PUMP INSTALLATION: Contractor - <br /> �t H.P. <br /> Type of Pump <br /> k PUMP REPLACEMENT-. , / / State Work Done - <br /> PUMP .RKPAIR: / / 'State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I� I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> k and the State of California pertaining to •or, regulating �aell'construction. , Within FIFTEEN DAYS <br /> after completion of �y work on a new we11, T 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 the be of my,knowledge and belief. I WILL CALLF'OR A GROUT INSPECT ON <br /> PRIOR TO GROUTIING W A FIN INSPE hk- <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE i � ._F ;' <br /> APPLICATION ACCEPTED BY ' DATE „ �{16 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPE ION I FINAL INSPECTION <br /> INSPECTION j3Y DATE 7—((0 INSPECTION BY DAT 701- <br /> hhe nu <br /> i, r U ,A94 v- 1-7/. /LIQ J ;f <br />