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L[.p, <br /> '- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 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 /> 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 ityen CENSUS TRACT <br /> Owner's Namefr41 Phone <br /> Address {l69U / 1:, City <br /> Contractor's Name License #c­r/Z93,4 Phone <br /> TYPE OF WORK (Check) :.- NEW WELL / / DEEPEN / - RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMPREPAIR / / 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 i <br />-.Domestic/public <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type 'of Grout <br /> Disposal Other Other Information <br /> Geophysical _ Surface Seal Installed_ By_:._.____. , <br /> PUMP INSTALLATION: Contractor sfJ-&J ' <br /> Type of Pumprzza H.P, . <br /> ey <br /> r ` <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />)ES�TRUCTIOI+I 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 f <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 know dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED <br />?RIOR TO GROUTI A FINA IN TITLE SAN JQAQU1�� PUMP �O��P�NY , <br /> - <br /> RAtiJ PLOT PLAN ON REVERSE SIDE) 9fifl F Pine Street . 11 <br /> FOR DEPARTMENT USE ONLY P. 0. Box 201 <br /> PHASE I {� <br /> APPLICATION ACCEPTED BY 1Od1,D�"TLfIlla, ,- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. , 1-74 �" �.%7 2M <br />