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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE. ICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> ! <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED Date_ Issued 1140 3 � 1918 <br /> (Complete In Triplicate) <br /> Application is 4ereby 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 J94qutn <br /> County Ordinance No. 1862-.and the Rules and Regulations of the San Joaquin Local. Health District: <br /> JOB ADDRESS/LOCATION d"J T-pq 1 PJ/E� CENSUS TRACT <br /> Owner"s NameL� l� -L Phone <br /> Address �7� 1� City ,;;, <br /> Contractor's Name -k / • %�C114 .License/0237 PhoA6it'&41VTo <br /> i <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN '/_7 RECONDITION' /_ DESTRUCTION /_J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT .i7 U <br /> Other <br /> , p <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 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 ,a <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal. � Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: , Contractor' 4 <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: ] State Work Done <br /> ,DESjRUCTI_ONOF WELL: - Well Diameter Approximate Depth' <br /> T Describe Material and Procedure <br /> I hereby agree to comply with all laws 'and'regulations of the San Joaquin Local Health ' . istrict .. <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 e <br /> WELL DRILLERS REPORT of the well and notify them before putting the..weil in use. The above <br /> information is true to the best of my knowledge, and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED; TITLE I <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEr�' �Ca <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY . 47 DATE INSPECTION BY DATE <br /> /Z7 T 2H <br /> E D�1426uQty_ I_74 <br />