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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&rOFFxCE[1SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781 <br /> j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 74t-3.5V <br /> 7ZI Py!Q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _7 <br /> Application is hereby made to the San(JComplete In oaquin Lo a1 Health District fl13- 4Lcr?- q <br /> ermit <br /> and/or install the work herein described. This application is made inrcomplancetwithastruct San Joaquin <br /> County Ordinance No. 1862 and the Rules/ and Regulations �Tof rhe San J aq� /u}in Local Health District. <br /> JOB 0DRE /LOCATION. <br /> / TRACT <br /> CT <br /> 4 Owner's Name I �� Phone <br /> Address <br /> City <br /> Contractor's Name <br /> �* License Phone,?, <br /> TYPE OF WORK (Check): NEW WALL <br /> r DEEPEN /? RECONDITION /7 DESTRUCTION <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLAC <br /> Other] <br /> EMENT /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES 5 47 -.•r-PIT PRIVY �. <br /> SEWAGE DISPO ELD CESSPOOL/SEEPAGE PIT /D D -OTHER <br /> PROFER Y LINE RIVATE DOMESTIC WEL tPUBLIC DOMESTIC WELL <br /> INTENDED USE TYP OF WELL _ CONSTRUCTION 3PECI 'ZCATIONS ' <br /> Industrial y" Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled _ <br /> asing <br /> Dia. of We11 ,C <br /> Domestic/public _i+ Driven Gauge �of Casing / <br /> Irrigation Gravel Pack "� Depth of Grout Seal. . � <br /> Cathodic Protection I _ Rotary Type of Grout <br /> Disposal 1. Other Other Information ion5uxface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: Sate Work Done <br /> PUMP:REPAIR: <br /> State Work Done <br /> ES;TRUCTION OF WELL: ( <br /> Well Diameter `"Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br /> and the 'State of California. pertaining to or regulating well c <br /> after completion of my work oonstruction. Within FIFTEEN DAYS <br /> ri a new well, I will furnish the Sari 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 e <�...r. . .r <br /> TITLE ' <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED k <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III NAL INSP TION <br /> INSPECTION BY DATE INSPECTION BY DAT v <br /> RE H 1426 Rev. 1-74 <br />�_ 1_7L 91u <br />