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G ik4 � SAN JOA UIDI LOCAL HEALTH DISTRICT <br /> R <br /> FOFx;O FIr.E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74r, 1 7110 <br /> THIS PERMIT EXPIRES 1.YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby made t6 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 ` �/ f/ CENSUS TRACT <br /> Owner's Name AIA 11je, Phone ' <br /> Address Ci <br /> te <br /> Contractor's Name License #110-3.Phone , 74(241 <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN "/7 RECONDITION '/ DESTRUCTION /7 <br /> PUMP INSTALLATION / I PUMP REPAIR -/-7—PUMP REPLACEMENT / <br /> other l/ / <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER n' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL #U <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing N <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type-of Grout <br /> Disposal Other Other Information: <br /> Geophysical .,_.,_.. <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION- .Contractor _ <br /> Type of Pump H.P. ! C <br /> PUMP REPLACEMENT: State Work Done ,0 ;� VL •� <br /> PUMP .REPAIR: :State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> pP p <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-of my. d a knle lief. T WILL CALL ,FOR A GROUT INSPECTION <br /> PRIOR TO 0 T G AND FIN �INSP <br /> SIGNED .. E <br /> 4 <br /> 4 <br /> DEA P T P ON REV SE SIDE a _ <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PXVrX fff/FXNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev_ 1-74� nM <br />