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- �- �oAk ��" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> 10— Telephone.,; (209) 466-6781 <br /> .- APPLICATION FOR WELL,�CONSTRUCTION OR PUMP PERMIT Permit No. yo <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued , <br /> I (Complete In Triplicate) <br /> ',Application is hereby made to the San Joaquin Local;Health District for a permit to construct <br /> 4` and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 axil the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 !?�l� n y'o,•y, ed,•� -` CENSUS TRACT <br /> r <br /> Owner's Name Phone <br /> Address �,� City <br /> t <br /> Contractor's Name � License # �—hone�'Z <br /> +3 <br /> 5 i <br /> x <br /> r TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION /-7 DESTRUCTION /-J <br /> PUMPiINSTALLATION lnW PUMP REPAIR49 PUMP REPLACEMENT <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 1 Cable Tool Dia. of Well .Excivation <br /> xT Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing <br /> _ Irrigation t Gravel Pack Depth of Grout Seal ~ <br /> Cathodic Protection " Rotary Type of Grout "- -_ <br /> Disposal Other Other Information ' . <br /> Geophysical Surface Seal •Instailed By: <br /> PUMP INSTALLATION: Contractor <br /> Type lrof Pump H.P. /. <br /> PUMP REPLACEMENT: / / 'State Work-Done <br /> PUMP .REPAIR: ;State Work Done <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 /> WEt-t-DRILLERS. REPO RT of the ',rell and notify them before putting the .well in use. The above <br /> "information is true to the best of my k wled e a belief. I WILL CALL FOR A GROUT INSPECTION } <br /> PRIOR i0 ING AND A FINAI INAZEjWpj <br /> SIGNED _ TLE <br /> D <br /> 'DOM-PLAN AN ON REVERSE SIDE] <br /> I' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE II / IAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ---DATE fes-°/ 7ur <br />� E H 1426" Rev. 1-7.4' <br /> ` 3/76 2M <br />