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#SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOH OFFICE USE: 1.601 E. Hazeltan Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67817 ' <br /> LIGATION FOR WELL CONSTRUCTION 0&,.PUMP PERMIT Permit No. <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 /> j and/or install the. work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 a d the Rules Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LO N �� CENSUS T CT <br /> Owner's Name Phone <br /> A3 0c;0W6.1 <br /> Address C; `_ City <br /> R <br /> Contractor's Name License Phone� � �6 96 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN RECONDITION I 7 <br /> ALl DESTRUCTION / <br /> PUMP INSTLATION �_PUMP REPAIR/—/—PUMP PUMP REPLACEMENT /7 <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. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . Driven,---.-.-: Gauge-of-Casing- <br /> ��="=Iton �� �GraveZ Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysicalrface Seal Installed By: <br /> Z. <br /> PUMP INSTALLATION: Contractor " 1 <br /> Type of Pump .P. <br /> PUMP REPLACEMENT: . / / State Work�Done C <br /> PUJET_REPAIRi" / / -State- Work Done <br /> DESTRUCTION OF WELL: Well Diaineter' 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 reguiating 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED `Q � , i TITLE <br /> DRAW PLIDT PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />' PHASE I <br /> f APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I OUT INSPECTION IPHASrjejII&NINSPECTIOX <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/7b 2M <br /> E H 1426 Rev. 1-74 <br />