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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OF CE USE: 1601E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> 4 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75=_5-13J° <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 install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations ofth San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U (� N/ Al <br /> !�� CENSUS TRACT <br /> cool <br /> Owner's Name Phone <br /> Address Q 3 A Al A, ; It, City <br /> Contractor's Name . <br /> �• F License # one <br /> TYPE OF WORK (Check): NEW WELL/? DEEPEN '/7 RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION/ PUMP REPAIR J' 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 L' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ---,�S- Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing c> <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 BY: <br /> PUMP INSTALLATION: Contractor Cie <br /> Type of Pump B.P. / <br /> PUMP REPLACEMENT: . j//_ State Work Done <br /> PUMP ,REPAIR: State Work Done a 4420 <br /> RES-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 utting.the..well in use.. . The above <br /> information is true to the•best of kno ed and bei i I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ING AND FINAL INSPECT <br /> SIGNED <br /> LE <br /> P PL ON REV E SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE / �L <br /> ADDITIONAL COMMENTS: .; <br /> 10001, <br /> PHASE II GROUT INSPECTIONE NSPBCTIO <br /> INSPECTION BY DATE INSPECTION DATE <br /> E H 1426 Rev. 1.74 2M <br />