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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> gOT;'Onfcn USE: 1601 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone: (249) x+66-»6781_ <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. . L__1VZ �J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate), <br /> Application is-hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or insCall 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 .M & Fd L ._ CENSUS TRACT <br /> 4f Phone Z <br /> Owner's Name <br /> - city , r <br /> Address <br /> npf1ZL/ -Z <br /> Contractor's Na ' Lc n'sePho <br /> k TYPE OF WORK (Check) : NEW WELL '�EEPEN /7�' REGOND*ION:��_ DESTRUCTION <br /> PUMP INSTALLATION / REPAIR I PUMP REPLAc ff I T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER�LINES�, i. PIT.,PRIVY <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHERCli <br /> \ <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL 3) PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OR WELL 'CONSTRUCTION SPECIFICATIONS <br /> Industrial - ale Tool y ; Dia. of Well Excavation <br /> ma stic/private Dril3b&d` . + . Dia. of Well Casing <br /> Domestic/Public <br /> Irrigation Gravel Pack kD ,iveni Gauge of Casing <br /> . Depth of Grout Seal - <br /> � , Cathodic Protection Rotary - Type of Grout C _ <br /> _ Disposal Other = Other Information <br /> Geophysical Surface Seal Installed B i 4 <br /> PUMP INSTALLATION: - Contractor <br /> f ..Type- of Pump A.P. j <br /> PUMP REPLACEMENT: / State Work Done <br /> 3 PUMP. .REPAIR: / / State Work Done <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 FT DAYS <br /> Dis <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- my knowledge and belief. ` I WILL CALL FOR A-GROUT INSPECTION <br /> PRIOR TO GLOMBRaD A I NSPECTION.. <br /> SIGNED TITLE <br /> .'(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 2ELT INSPECTI PHASE III FINAL IN SPECT N <br /> INSPECTION BY C, DATE INSPECTION BY L, DATE <br /> E H '1426- Rev. 1-74 4Z75 2M <br />