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r iN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> i FOS OFFICE USE; � x. 4601 E. Hazelton Ave. , Stockton, Calif, ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR 44Ed CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 5 � <br /> j (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 Jo$quin� <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT - <br /> Owner's Name 0 Phone -- /� <br /> Address <br /> City <br /> Contractor's Name LU / f`+ License # _ <br /> C Phone <br /> TYPE OF WORK (Check) : NEW WELL '/�/" DEEPEN /-7 RECONDITION /-' DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP PLEPLACEMENT • R <br /> .,> y t <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 CONSTPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL RUCTION SPECIFICATIONS t <br /> Industrial � Cable Tool Dia, of Well Excavation � C1Domestic/private. Drilled Did.. of Well Casing x <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 Surface Seal Installed B : <br /> PUMP INSTALLATION: Contrdctar <br /> Type .Pump ,z 4 g'A <br /> v H.P. <br /> 1 <br /> PUMP REPLACEMENT: . /-7 State Work'DOne• tt <br /> PUMP -REPAIR: f�/ State Work Done j <br /> DESTRUCTION OF WELL: Well Diameter <br /> . 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"cons true tion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San 'Joaquin Local -Health District a <br /> WELT, 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 FOIL A GROUT INSPECTION <br /> ?RIOR TO GROUTING AND A FINAL INSPECTION. �1 <br /> SIGNED 4TITL "y <br /> (DRAW PLOT:PLAN ON REVERSE SI ' <br /> FOR DE SE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . 1 <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE 11 GROUT INSPECTION PHASE U I/I:INAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY 1-;el DATE <br /> E H 1.426 Rev. 1-74 7 77 2M /t <br />