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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0T;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone;. p . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 �o Rules and Regulations of the San -Joaquin Local Health. District. <br /> JOB ADDRESS/LOCATION - Lv I -0 CENSUS TRACT <br /> Owner 1 s Name LIZ, Phone , 211a zz� <br /> Address _ � 5-5.H.1m U }, City '. <br /> Contractor's .NaonJ V,- License # Phone <br /> _ :.:H'"-.__._ +�,-r. ..y. ��-.•— _ ..d. :��- - 4 t`-t.-�:c'�� _4- '.: — '.�_.--_--.-'� pry <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN ,/7 RECONDITION % (. _..DESTRUCTION f7 <br /> ',PUMP INSTALLATION / / PUMP REPAIR ,, PUMP REPLACEMENT /- 1 <br /> y 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' P-UBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .Industrial Cable Tool—, 6f'Well Exdavat16n f <br /> Domes tic/pr"ivate Drilled s Dia. of Well Casing <br /> Domestic/public Driven, � Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �1 <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed BY: . . . <br /> PUMP INSTALLATION: Contr ctor <br /> Type of Pump a H.P. o� <br /> PUMP REPLACEMENT / / State Work Done <br /> LUMP '.REPAIR: / State Work Done vim+ <br /> DESTRUCTION OF WELL: Well Diameter Approximate"'Depth <br /> — Describe Materialnd 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 weld:; 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 kno:'WAedge and belief. I WILL CALL FOR A4 ROUT INSPECTION <br /> PRIOR TO GROJITING AND A INAL' INSPECTION../ <br /> SIGNED TITLE <br /> DRAW�TLOT PLAN ON REVERSE SIDE <br /> r,MR ftARTMENV USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED L 1►JO°T/ DA <br /> ' ADDITIONAL COMMENTS: ►4 <br /> PHASE II GROUT INSPECTION PHAS III SPECTI N <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> 4 , <br /> F H I x26 Raw- 1-74 <br />