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SAN 'JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PEMT Permit No. <br /> THIS PERMIT EXPIRES 1. YEAR FROM 'DATE ISSUED Date Issued //-/-7/-7 <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 Joaquin <br /> County Ordinance No. 1862 and,.the Rules and Regulations of the Sats Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONSUS TRACT <br /> Owneris Name Phone 9 31 -33 4'-2_ <br /> Address <br /> City ; <br /> Contractor's NameLicense [ Phone_r, <br /> TYPE OF WORK (Check) : NEW .WELL /`�ZDEEPEN / / RECONDITION / / DESTRUCTION / <br /> PUMP INST—ALLATION /c PUMP REPAIR f-1-pump. ; REPLACEMENT-17 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TAN S WR 5 PIT PRIVY <br /> SEWAGE DISPOSAL FIELi/ldCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC 1DONESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �- <br /> Industrial Cable Tool Dia. of Well Excavation <br /> z---Domestic/private Drilled Dia. of Well Casing f" <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout .Seal. ���� <br /> Cathodic Protection r___-Ratary Type of Grout q, „ � <br /> Disposal Other Other Information <br /> Geophysical Surface .Seal Installed By: <br /> PUMP INSTALLATION: Contractor (f ` <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: l / State Work Done <br /> PUMP -REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth' k <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 ''constructi.on. Within FIFTEEN BAYS <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 knowledge and belief. I WILL CALL FOR A. GROUT INSPECTION <br /> PRIOR TO GRO I D .A FINAL INSPECTIO <br /> SIGNER TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III/FINAL INSP TI <br /> INSPECTION BY DATE �1�� INSPECTION BY �_�1 DATE <br /> el-Viv- Lai <br /> E H 1426 Rev- .1-74 <br /> -b777 _ 2M <br />