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SAN JOAQUIN LOCA, HEALTH DISTRICT <br /> FOS 0 FIf'E USE: 1601 E. Hazelton Atte. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> THIS PERMIT EXPIRES I 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 /> E and/or install the work herein described. This application is trade in compliance with San Joaquin <br /> County Ardinance No., 1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSAOCAT30Ns i2 7 A/ .zS,ee i CENSUS TRACT <br /> Owner l s Name Cdc nAy Ba., /,�rj Ph one ' <br /> Address , / % dti 45 City <br /> Contractor's Name �.► License #r J'-Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /7 RECONDITION /—f DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> I' 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 <br /> Industrial CONSTRUCTION SPECIFICATIONS Cable Tool Dia. of Well Excavation � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation �. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection- ; " Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical <br /> Surface Seal Installed Byt <br /> PUMP INSTALLATION: .:' Contractor <br /> Type .of Pump <br /> H.P. / <br /> PUMP REPLACEMENT: . L/ State Work Done <br /> y , <br /> PUMP REPAIR: - - / / State-Work•Done ri Y a <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> - <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' kno ledge and belief. I WILL CALL FORA GROUT INSPECTION 1 <br /> PRIOR TOG UTING AND A FINAL I SP I <br /> SIGNED ITLE <br /> (D W PLOT PLAN ON VERSE SIDE <br /> FOREPARTMENT USE ONLY <br /> PHASE I . <br /> APPLICATION' ACCEPTED BY i <br /> ADDITIONAL COMMENTS; 40, DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY 1- DATE "7r <br /> - E H 1426 Rev. 1-74 f.i�c <br />