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P<o. f lam"`` SAN JOAQUIN LOCAL HEALTH -DISTRICT <br /> FOFx�OF CE USE: i601. E. Hazelton Ave. , Stockton, Calif. <br /> I� Telephone: (209) 466 -6781 <br /> l APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. asp <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 trade 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 c S L'� f �� 1f CENSUS TRACT <br /> Owner's Name ,/' Phone <br /> Address , C� -- -f4 ��-- d City (_rle 65 <br /> Contractor's Name 0 License # 0ne6?-� <br /> E TYPE OF. WORK (Check): NEW WELL -/7 DEEPEN/? RECONDITION f_7 DESTRUCTION f7 <br /> PUMP INSTALLATION - f PUMP REPAIR-67-pump REPLACEMENT f 7 <br /> Other' /—/ <br /> DISTANCE TO NEAREST: SEPTIC1TANK SEWER LINES PIT PRIVY <br /> f SEWAGEIDISPOSAL 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 Q <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation a Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> t Disposal : . _- Other Other Information ' ' <br /> I Geophysical Surface Seal Installed_By: <br /> PUMP INSTALLATION: Contractor , -D <br /> Type .of Pump <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP '.REPAIR: / State Work Done <br /> R - V'� <br /> 1?E&TRUCTION 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 '-construct:ion. 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.of my..knowtedge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING"AND A FINAL P ON. <br /> SIGNE TITLE <br /> �- <br /> W PLOT PLAN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE y <br /> ADDITIONAL COMMENTS: <br /> PHASE II G N CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 6 <br /> 1 E H 1426 Rev. 174 4/75 2M <br />