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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL~ OF C USE: 1601 E. Hazelton Ave. Stockton. Calif. <br /> Telephone: (209) 466-6781 � <br /> F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z=/b�S;� y <br /> G ' <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 of the San Joaquin Local Health District. # <br /> JOB ADDRESS/LOCATION Q (��.,��� ,� _ CENSUS TRACT ' i <br /> Owner's Name Phone <br /> Address 2 .e 'Arc,of o City f <br /> Contractor's Name u License #/$3-?VrThone <br /> f <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> E� Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i 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 Cable Tool Dia, of Well Excavation <br /> --' y Domestic/private Drilled Dia, of Well Casing <br /> E1 Domestic/public Driven Gauge of Casing <br /> R Irrigation Gravel. Pack Depth of Grout Seal <br /> ��. Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: % / State Work Done <br /> PUMP REPAIR: /K/ State Work Done .,/ <br /> VSEL <br /> DE§JRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and. Procedure <br /> Thereby 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. m knowledge--acrd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G TI AND A FINAL I U <br /> SIGNED y TLE <br /> RAL PLO LAN ON RE_9ffk3E SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE_ <br /> ADDITIONAL. COMMENTS: ' <br /> PHASE II GRODT INSPECTION P I /IINAL INSPE ION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> E H 1.426 -Rev. .'1-74 <br />