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SAN JOAQUIN LOCAVEEALTH-DISTIt-ICT" <br /> FOE�.Z FI E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 andj Regulations of the San -Joaquin Local health District. <br /> ,TOB ADDRESS/LOCATION ®`1/ 446, CENSUS TRACT <br /> Owner's Name `Phone <br /> l <br /> Address W� 1ae-►tel _ .� city m o� <br /> Contractor's Name 'IX/ License # p hone Y 7 G S <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/7 RECONDITION %T DESTRUCTION /—T <br /> PUMP INSTALLATION / / PUMP REPAIR-f- 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 OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool., Dia. of Well Excavation <br /> e Domestic/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 B : <br /> PUMP INSTALLATION: Contractor- <br /> Type <br /> ontractorType of Pump H.P. A <br /> J?UNP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: /X/ State Work Done _ ,.. <br /> c� <br /> DESTRUCTION 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"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 knowl --and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSP ION <br /> SIGNED g� TLE <br /> (MADIPLL46T PLAN ON R SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY L4 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHAS I F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 .—Rev. 1-74 _ 2M . <br />