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SAN J'OAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 160,1"1. Hazelton Ave. , Stockton,1Cal <br /> -- <br /> Telephone ; (209) 4.66-6781' -� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 r <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 applications 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 / '1 l <br /> CENSUS TRACT <br /> Owner's Namefi Phone <br /> Address vl ay. Ve Cityc,; <br /> f <br />�I Contractor's Name C .j License It_gmlgz -none <br /> TYPE OF WORK (Check) : NEW WELL U DEEPEN / / RECONDITION I l DESTRUCTION /_7 <br /> PUMP INSTALLATION �/ PUMP REPAIR/' t/ PUMP REPLACEMENT /7 <br /> Other / J F <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES -- PIT PRIVY <br /> SEWAGE DISP SO AL FIELD CESSPOOL/SEEPAGE PIT / OTHER <br /> PROPERTY LINE/IPRIVATE' DOMESTIC WELL-4 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool-- Dia. of Well Excavation /2 I/ <br /> __ XDomestic/private Drilled Dia: of Well Casing <br /> Domestic/public Driven Gauge of }Casing /2 <br /> d <br /> Irrigation Gravel Pack Depth o€Grout Seal <br /> Cathoidl�c Protection Rotary _ Typ of Grout 5 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump .e. H.P. <br /> PUMP REPLACEMENT: . J / State Work Done e <br /> PUMP .REPAIR: / / State Work Done # �1 <br /> DESTRUCTION OF WELL: Well Diameter I 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 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORrAF <br /> e well and notify them before putting the -well in use. The above <br /> information is tr my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> F PRIOR TO GROUTi ANAL SP IW. <br /> SIGNED TITLE <br /> DRAW 1 PLOT PLAN ON .RE ftSE SIDE) <br /> OR D P41erMENT USEFONLY <br /> PHASE I <br /> APPLICATION. ACCEPT Y V '1 —EL DATE <br /> ADDITIONAL COMMENTS: -r <br /> PHASE II GROUT INSPECTION P S I I/FI AL INSPECTION <br /> I' cINSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. '1-74 .. � ' ... . <br /> 3/76 2M <br />