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SAN JOAQUIN LOCAL HEALTH DISTRICT G 4 <br /> FOR.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. >_Z_s1a 4d <br /> THIS PERMIT EXPIRES I 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name r Phone w <br /> Address �- Gni' CityL19 4Pl� <br /> LicensePh <br /> 4 �¢` one '. 6 <br /> Contractor's Name _. <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP, INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <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 0 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �� <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By, E'G <br /> PUMP INSTALLATION: Contractor <br /> Type of" Pump H.P. <br /> PUMP REPLACEMENT: / 7 / State Work Done <br /> PUMP -.REPAIR: , / / State Work Done <br /> DES,TRUCTIONmOF 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 wel.l'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 puttingthe..well in use. The above <br /> information is true to thembest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE r +, <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 0 a._- <br /> PHASE I ,F 5��� ; <br /> APPLICATION ACCEPTED BY rt DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHA II QROUTqINSPECTION P /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE S 7 <br /> E H 1426 Rev..; 1-74. <br />