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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WCL 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 Jogqu3 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> � . a r, F <br /> JOB ADDRESS/LOCATION 1' 1 . . �; f � 4. '�`�a�'if�r CENSUS TRACT <br /> . . , <br /> Owner's Nature l � . ; , I 4 �> � ��� F � Phone <br /> Address City <br /> f ��r <br /> 5 r <br /> 1 i <br /> Contractor's-Name, A / ; el e A � >.; �:.-��:= t` �, License.��' '•_Phone` � ���l� <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL A7 DEEPEN /_ RECONDITION L- DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK ;1, - SEWER LINES` r=j:'., PIT "PRIVY <br /> SEWAGE DISPOSAL FIELD,. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUSLI+�-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �T <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X _ Domestic/private �-k: Drilled Dia. of Well Casing , " <br /> Domestic/public Driven Gaugeof Casing '._ <br /> IrrigationGravel Pack Depth, of Grout Seal <br /> Cathodic Protection *. Rotary Type of Grout 47 > ' <br /> Disposal Other Other Information' <br /> Geophysical Surface Seal Installed BY: z.1,11f % <br /> PUMP INSTALLATION:' Contractor , A' <br /> Type of Pump r <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 Stateof 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 Healt4 District a <br /> WELL DRILLERS REPORT of the well and notify them before patting 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 GRG, 0C AND k- INAL INSPECTION. <br /> SIGNED ,' s s TITLE r . <br /> DRAW PLOT PLAN aN REVERSE SIDE) . . <br /> yt , <br /> FOA DEP TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE..'l,"'4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Re 1/7? _ 2M <br /> Rev. 1-74 _� _:.::: <br />