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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �F FOR!OF "CE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z?z_-3A�P p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- <br /> (Complete in Triplicate) <br /> Application .is hezeby made to the San Joaquin Local Health District for a Permit -to construct <br /> R and/or install the work herdin 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 II WjL,t ­PCENSUS TRACT <br /> E. Owner's Name 4014 q 4 r � a 4 Phone <br /> Address G 7 7 Al too-a. , City <br /> Contractor's Name L . <br /> } <br /> F License # / j 2LJ:Phone y- � <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPE91-7 RECONDITION /7 DESTRUCTION /_7 i <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT % f <br /> f Other]/ <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDTSPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation `�•i <br /> Domestic/private. i Drilled Dia. of Well Casing. <br /> T"- Domdstic/public ' + Driven . ck Gauge of_Casing_ <br /> Irrigation i /Gravel"Pai Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal i Other _ _ Other Information <br /> Geophysical - Surface Seal Installed B <br /> Pump INSTALLATION: Contractor �� <br /> Type of Pump S`c <br /> x i <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,- EPAIR: k7 State Work Done e. <br /> i i <br /> E&TRUCTION OF WELL: Well Diameter A Approximate Depth � <br /> Describe Material and Procedure <br /> F . <br /> I hereby agree to comply withlall 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 REPORT of the well and notify them before putting..the .well in-use.. The above <br /> information is true to the-best-0f kn wle nd belief. <br /> PRIOR TO GROI WILL CALL FOR A GRO1dT INSPECTION <br /> GROUTING AND A FINALE NS CT <br /> SIGNED TLE <br /> I <br /> � . /,(PAW PLOT PLAN ON RE SE SIDE <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GRO SP TI PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> lE H 1426 Rev. 1-74 , <br />