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-- 0C,d . _i <br /> as In SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> FOSlO ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. E <br /> Telephone: (209) 466--6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZLL";,0 1 <br /> THIS PERMIT EXPIRES l 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 wade 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 __L&&.3 2 CENSUS TRACT j <br /> k <br /> Owner's Name /qr7 Phone <br /> Address , 6: ,_.._,.._ �+ City <br /> Contractor's Name License # M-72-- Phone <br /> 7&` <br /> Af <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN J-7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /-/ PUMP REPAIR /% PUMP REPLACEMENT <br /> Other /7 <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 /> S Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br />_ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary irypeofIGrout— s <br /> Disposal , Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor elf <br /> ", <br /> Type of Pump / H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> 1. ; <br /> PUMP !REPAIR: /7 State Work Done <br /> ES;TRUCTION 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..well in-use.. The above <br /> information is true to the-best. my knowle-d-g-a and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO UTING AND A FINAL I <br /> SIGNED . ITLE ,�,� <br /> (DIRAW-PLOT PLAN ON WrFRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B D E <br /> ADDITIONAL COMMENTS:8 )tow <br /> PHASE JI,GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />