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_ ArSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOvr 'G "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 l YEAR FROM DATE ISSUED Date Issued Z_7' Z_;�K <br /> E � <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District fora permit to. construct <br /> and/or install the work;iherein 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 /> 0 / <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' <br /> Owner's Name j'. - Phone E� <br /> ,M <br /> r Address PL lCa'l City <br /> ` Zz <br /> Contractor's Name �! �!� f, / ��Q� -_- License #����hone 4k- � <br /> TYPE OF WORK (Check) : .INEW WELL DEEPENC RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> ;� .'. ..""-�thea/_/-�-•------- -- — <br /> DISTANCE TO NEAREST: SEPTIC TANK _r 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 /> r Industrial l---Cable Tool Dia. of Well. Excavation (} <br /> //Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical :�.: Surface Seal Installed B <br /> PUMP INSTALLATION: Contracto <br /> Type of <br /> ; PUMP REPLACEMENT: �/ / State Work Done <br /> j PUMP .REPAIR: V / State Work Done <br /> 0 <br /> DES•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 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 txuerto��the best of my knowledge and belief. I .WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING.- D X FINA INSPECTION. <br /> SIGNED TITLE ca y <br /> �p (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> .._ I Pwo-._.. _.I ROUT�INSPECTI P_HAS FI AL INSPECTION- <br /> , INSPECTION BY 1 4., DATE INSPECTION BY ' DATE f <br /> E H 1426 .', l- r1�4 06/77 2M <br /> :� ,. Rev - 7 � _ . <br />