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SAN- JOAQUINyLOCAL HEALTH DISTRICT `� 4 <br /> iCF0E 0 ICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. d' <br /> ;IM <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t 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 Distract for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> 1. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> / CENSUS TRACT ' <br /> J;OB ADDRESS/LOCATION I L� o �G f <br /> I <br /> !1 � <br /> er's Name Phone <br /> I. a - �srir <br /> Address al . ,�i� ' t City - <br /> f Contractor's Name os a64 License �� �Phone� <br /> TYPE OF.WORK (Check) : NEW WELL /_ DEEPEN /� RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT' <br /> -- /—T -" <br /> other % <br /> . <br /> DISTANCE TO NEAREST: `SEPTIC TANK ZL2 SEWER LINES PIT PRIVY <br /> t. <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> :PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE 11 TYPE OF WELL `t - ` CONSTRUCTION SPECIFICATIONS <br /> Industrial �! _.L�able Tool Dia, of Well Excavation <br /> IM omest c./_priva.te DraILQe Aia.: of_�Wel.l Casing�.r-� <br /> ill. Domestic/public! Driven Gauge of Casing ar <br /> :IIrrigation I Gravel Pack Depth;-of Grout Seal <br /> IM Cathodic Protection Rotary - :` .- _Type of =Grout <br /> JM Disposal �� Other s Other 'In- f-ormation <br /> Geophysical i�. Surface Seal Installed : <br /> B3 { <br /> (PUMP INSTALLATION: Contractor - A° �+ p <br /> I I Type of Pump H.P. <br /> PUMP REPLACEMENT: II / / State Work Done <br /> PUMP REPAIR: / / State Work Done_ <br /> DESTRUCTION OF WELL: Well Diameter, Approximate Depth_ <br /> Describe Material and Procedure of <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District. <br /> 'fnd the State of Cali?fornia pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> 4 -.ffter completion of my work on a new well, 'I will furnish the San Joaquin Local Health Distr: ct- <br /> WELL DRILLERS REPORT 'hof the well and notify them before putting- the well in use.. The above . <br /> ifinformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPEC7TON <br /> PRIOR TO GROUTING A4DII A F4kAl I TION. <br /> fGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> fj/ II '.OR EPARTMENT USE ONLY <br /> IPHASE T <br /> APPLICATION ACCEPTED BY DATE Z3 <br /> (!ADDITIONAL COMMENTS: I r <br /> PHASE I! GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , ,/ DATES <br /> _� II -- - b/ 7.,- 2M <br /> k ;,E:.H 1426 -Rev. 1=74 <br />