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� SAN`�J'OAQUTN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1'1601 E. Hazelton Ave. , Stockton, Calif. <br /> i� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR',PUMP PERMIT Permit No. 2ol- e 4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued x.:126 <br /> (Complete In Triplicate) <br /> Application is hereby made do 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 S iJoaquin Local Health District. <br /> JOB ADDRESS/LOCATION D; .� � CENSUS TRACT <br /> Owner's Name Phone 3 d� <br /> Address 4 d -(�• •��Lu� -mac &V City' <br /> Contractor's Name I License # Phone - C ' <br /> TYPE OF WORK (Check): NEW W'ELL'/Tl DEEPEN RECONDITION /7 DESTRUCTION /_7 <br /> PUMP lNSTALLATION I / PUMP REPAIR '/ / 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 WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE %TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 6, Cable Tool Dia. of Well Excavation <br /> 4—Domestic/private 'i�33rilled Dia. of Well Casing <br /> Domestic/public "N Driven Gauge of Casing <br /> Irrigation it Gravel Pack- Depth of Grout Seal <br /> �-� thodic Protection JI 4--Rotary Type of Grout <br /> Disposal. 4j Other Other Information` ' <br /> Geophysical Surface Seal Installed By! <br /> PUMP INSTALLATIONL Contractor <br /> ,Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done - <br /> .. <br /> PUMP .REPATR: State Work Done <br /> ip <br /> DESTRUCTION 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 .Tae3l. in..use... The above <br />. information is true to the-best.of -my..knowledge and belief. I WILL. CALL FORA GROUT INSPECTION <br /> PRIOR TOG OUTING AND AL INSP IQ . <br /> SIGNED TITLE Q <br /> (DRAW T PLAN ON REVERSE SID <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: IL <br /> PHAS + GROU INSPECTIO PHASE FIN INSPECTION <br />( INSPECTION BY ATE - �J I INSPECTION BY DATE <br /> H-1426' Rev. 1-74 ��. ° G 475 2 <br />