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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB4OFF CE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209): 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�4-re) lA <br /> THIS PERMIT EXPIRES 1 YEAR FROM RATE -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 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 �,ry.� L.._._._A4 fez, CENSUS TRACT <br /> Owner's Name -- - /I/1,. a � � Phone <br /> Address City <br /> Contractor's N LLicense home44 1;76? <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIRf7 PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE TMSTIC L 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 G <br /> Domestic/public Driven Gauge of Casing L <br /> Irrigation Gravel Pack Depth of Grout Seal - v <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information * <br /> Geophysical Surface SSgal Installed <br /> PUMP INSTALLATION: Contractor ~ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , E7 State Work Done <br /> PUMP 11122W. -7 State Work Done <br /> 1?ES�UCTION OF WELL: Well Diameter <br /> 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'..wel . in.use.... The above <br /> information is true to tha�best of- my le abelie . I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING AND FINAL INSP <br /> SIGNED D' W REVKRSEITLE <br /> PON cs f' r <br /> SIDE' <br /> R <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL CO*9WS <br /> PHASE II GROUT INSPECTION PRUVIIIIFI1111L INSPBCTION <br /> INSPECTION BY DATE INSPXCTION BY DATE <br /> E R 1426 Rev. 1-74 r. . ,-"•• <br />