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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOflrOFFIC& USEEq'�jjjl'�APPLICATION <br /> 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Teephone: (209) x+66-6781 <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22�62Z*,J} <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1-11-2,7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> rand./or install the work herein described. This application is-made in compliance with San Joaq a <br /> County Ordinance No. ,1862 and the Rules and Regulations of <br /> of the San Joaquin Local Health District._; <br /> JOB ADDRESS/LOCATION 1 a CENSUS TRACT <br /> Owner's Name Phone q-7 7- 7Z22 } <br /> Address ` City <br /> Contractor's Name License # Phone � G;��6S` 7 <br /> TYPE OF WORK (Check): 11NEW WELL /XT DEEPEN ,/7 RECONDITION /_7 DESTRUCTION f7PUMP INST LATION / /—PUMP REPAIR —PUMP REPLACEMENT. /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK /Q Q SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL.' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial i� Cable Tool Dia. of Well Excavation- /z <br /> �( Domestic/private! Drilled Dia. of Well Casing " <br /> Domestic/public Driven Gauge �of Casing � /Q <br /> f Irrigation Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information �. F. <br /> Geophysical Surface Seal Installed By: ... <br /> PUMP INSTALLATION, �iContractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: !� / / State Work Done <br /> PUMP '.REPAIR: �. .:-j_/_State Work Done <br /> MS-1 RUCTION OF WELL: " Well, Diameter Approximate Depth <br /> :k Describe Material and Procedure' <br /> j. 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 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 /> i WELL DRILLERS REPORT of the well and notify them before putting the- well in-use.--"The above <br /> r <br /> information 'is true to the best of my knowledge and belief. 'IrV LL CALL FOk A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL INSPECTION. <br /> SIGNED \ TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i. PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I CT ION PHASE III/FINAL INSPECTION <br /> INSPECTION BY J ;:.n BAT - /? INSPECTION BY DATE /!- :.r <br /> R µEH 1426 Rev. 1 74 1=74 2M,-” <br />