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(a v.i lb i SAN JOAQUIN LOCAL k1EALTH DISTRICT <br /> FO&�0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _s-7s- <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 is made in compliance with San Joaquin' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. , <br /> JOB ADDRESS/LOCATION o� -�_.kJ �_ a cC'7 �-. a ��® _ CENSUS TRACT <br /> Owner's Namey Cr h c'3,,, :2 t2. Phone �I <br /> Address i e eaz City � .., <br /> Contractor's Name - License # / .3 �"Phone g46 y 7�7 , <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION T <br /> PUMP INSTALLATION / / —PUMP REPAIR Z/PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> + Domestic/public Driven Gauge of Casing `s <br /> K _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal. Other Other Information r <br /> Geophysical Surface Seal. Installed BX: <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pumper ,e 4 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP.REPAIR;. -7 State Work Done e r" - 3 1AP_ 00�) /*P <br /> ,PES•TTRUCTION OF WELL: Well Diameter Approximate Depth <br /> E <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 of my 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 m knowledge-a belief. I WILL CALL FOR-A -GROUT INSPECTION <br /> PRIOR TO G NG AND A FINAL INSPE � I <br /> SIGNED TLE <br /> (BfLA"LOT PLAN QN RZVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B ; DATE <br /> ADDITIONAL COMMENTS; <br /> PHAW TA GR0VT INSPECTION PHASEFINAL NSPECTIO <br /> INSPECTION BY DATE INSPECTION BY ATE Z� <br /> i't E H 1426 Rev. 1- 74 1-74 <br />