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Ca SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -� G 5 <br /> FO OFP3 USE: 1601 E. Hazelton Ave. ; Stockton, Calif. i <br /> Telephone (209) 466--6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 'f <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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local -Health District. <br /> ��]]'�J''Q ,� ` t[ CENSUS TRACT ' <br /> -JOB ADDRESZLOGATION c< /wt 4-<<v �olra�`a � S�year 0J- f <br /> Owner's Name ,Ea ✓ o►!ri /L Phone <br /> Address F-0, k0ox //-5City, -/-w ✓. a•� I <br /> Contractor's Name `License # �,� _ Phone C 7� <br /> i <br /> S <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_/ DESTRUCTION /_T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled -Dia. of Well Casing <br /> Domestic/public Driven .. ,-Gauge-of Casing <br /> fIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Other Other Information <br /> Geophysical Surface Seal. Installed -By: <br /> PUMP INSTALLATION: Contractor .¢) 4L,. <br /> T.yPe of .Pump H.P P. <br /> F <br /> PUMP REPLACEMENT: /X/ State Work Done,-' 2 <br /> PUMP REPAIR: / / State Work Done <br /> ' DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> k 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 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 /> FPRIOR TO GROUTING AND A FINA C ION <br /> k; SIGNED R — TITLE <br /> (DRAW PLOT PLAN EVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IZZe <br /> APPLICATION ACCEPTED BY DATE 4Z - <br /> ADDITIONAL COMMENTS: ` <br /> PHASE Ik 9ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ 4d?. DATE <br /> f <br /> n;77 2M:_. <br /> E H 1426 Rev- . 1-74 _. - <br />