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' : SAN JOAQUIN LOCAs, HEALTH DISTRICT <br /> '.= FOBiOFF'ICE USE: 1601 ,E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4-11 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /o_ �L_2,5 <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 ie made in compliance with Ban Joaqu�n� <br /> County Ordinance No. 1862 and the Rules and Regulations of the a Jaaquin Local Health District,. <br /> JOE ADDRESS/LOCATION f / 2 �/ c4CENSUS TRACT <br /> Owner's Name _ <br /> ire Phone ,- <br /> -Address <br /> City <br /> Contractor's Name <br /> License # /3 Phone <br /> 'TYPE OF WORK (Check): NEW %!WELL DEEFER 7/7 RECONDITION _ , <br /> T DESTRUCT %j <br /> 1_7 /� ON <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT 1-7 <br /> - Other /% -- <br />!DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> �j SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> APROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia,. of Well Excavation <br /> Jff <br /> Domestic/private Drilled Dia..-of- Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal w�' <br /> Cathodic Protection _�_ Rotary Type of Grout <br /> _ <br />'—Disposal' Other <br /> Other, Information <br />_Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of ump <br /> H.P. <br /> PUMP REPLACEMENT: . / State Work Done <br /> PUMP ,REPAIR. /_7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all Daws 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 <br /> TELL DRILLERS REPORT of the well and notify them before putting. the..well. in.use.. The above <br /> Lnformation is true to the-best -of.my-knowledge and belief. I_WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GR UTING AND A FINAL INSP 0 . <br /> SIGNED TITLE <br /> (DRAW T PL ON REV SE SIDE <br />'RASE I 4 ��� FOR DEPARTMENT USE ONLY <br /> C1'P CATION ACCEPTED-HY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHAS I ROUT INSPECTION PHASE 11 FINAL INSPECTION <br /> CNSPECTION BY DATE — - 5� INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 - ...a <br />