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4-� 90V1 � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOTO;4F ICEE USE:_" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Za_ L3FP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued 7-7-26 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct 1 <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 Sart Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Namero Phone <br /> Address t� <br /> - - City <br /> Contractor's Name License # / <br /> kj Phone d <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN - RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION PULP REPAIR "/? PUMP REPLACEMENT /7 7 , <br /> Other /% <br /> I <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 /> k 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 Type of Grout <br /> Disposal Other Other Information . <br /> 'Geophysical <br /> Surface Seal. Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump _r ,d /� H.P. <br /> PUMP REPLACEMENT. . / State Work--Done ; <br /> PUMP : p State Work Done <br />]E&TRUCTION OF WELL: Well. Diameter ! <br /> Describe Material and Procedure Approxi ate Depth <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 /> TELL DRILLERS REPORT of the well and notify therm before putting.. the..well:- in.use.,.. .The above <br /> Lnformation is true to the-best-of m ..knowledge a belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROU ING AND A FINAL INSP �. , <br /> iIGNED -- <br /> TITLE <br /> D V-FLOT PLAN ON ERSE SIDE) <br />,RASE I FOR DEPARTMENT USE ONLY <br /> 1PPLICATION ACCEPTED BY ATE <br /> WDITIONAL COMMENTS: ,,� �. <br /> PHASE II GROUT INSPECTION PHASEII FI AL YNS CTION <br /> INSPECTION By DATE INSPECTION BY DATE <br /> E H 1426 izam- 1_7A' f <br />