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''I 1 <br /> F Q. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO "IF <br /> CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 4 <br /> " II <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76�/-s� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?-,7 -21, <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 workliherein described: This application is made in compliance with San Joaquin <br /> County Ordinance No. 18 2 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> 14 t 44�"�` ,i e n •we�� �m o' CENSUS TRACT <br /> JOB ADDRESS/LOCATION Fal fro f/ e 44 �e <br /> Owner's Name � ✓tea p Phone ! <br /> Address <br /> �- c0 �•-! v.e City <br /> nV <br />` Contractor's Name License # 711-3 7ys�one Y2-d 76 <br /> I if <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN '/ RECONDITION DESTRUCTION f7 <br /> .PUMP INSTALLATION / / PUMP REPAIR � PUMP REPLACEMENT <br /> IT <br /> rother / / ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE FIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �7 <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool A Dia. of Well Excavation <br /> Domestic/private Drilled 'Dia. of Well Casiri'g, - <br /> ! Domestic/public Driven M Gauge of Casing <br /> "Irrigation Gravel Pack Depth of Grout Seal <br /> I ""` 'f Rotary a of Grout <br /> 1 Cathodic Protection y � <br /> Disposal " Other Other Information <br /> i <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor f <br /> d <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP :REPAIR: / State Work Donee_ <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth ` <br /> ' - Describe Material and Procedure <br /> I hereby agree to comply with all laws 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 ofmy work on a new well, I 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 to the•best of my knowledge....and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING ANDFINAL INSPE N. � <br /> ITLE <br /> SIGNER. <br /> RA PLO , PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II11GROUT-INtPECTION PRASE III INAL INSPECTION <br /> INSPECTION BY 71' DATE INSPECTION BY DATE ' <br /> ` J1174 <br /> 1-74 2M <br /> EH 1426 , Rev. 4 <br />