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SAN JOAQU.IN I4OL'A€, ri <br /> EALTH DISTRICT <br /> FOF OF�E USE: <br /> 1601. E. Hazelton Ave, , Stockton, Calif. <br />` Y <br /> Telephone : (204) 466--678]. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Compete 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 J L.. �. - (�ta?L�! 1p� ��_ - _-� CENSUS TRACT <br /> Owner's NameT� 4 PhoneN <br /> dress C;ity <br /> Ad —i <br /> Contractor's Name License # Phone <br /> J <br /> TYPE OF WORK (Check) : NEW WELL X DEEPEN I I RECONDITION /_% DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / 11U_MP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK "jS SEWER LINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD ;01D)'- CESSPOOL/SEEPAGE PIT OTHER <br /> ROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industri:al Cable Tool Dia, of Well. Excavation _ <br /> _ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> a <br /> Irri non <br /> g - Gravel Pack Depth of Grout Seal _? _ <br /> Cathodic Protection x Rotary Type of Grout <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H=p= <br /> PUMP REPLACEMENT: / '/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES,TRUCTIO14 OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> Thereby 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 /> PRIOR TO GRO TING. AND A INAL IN`PECTION. ` <br /> SIGNED <br /> TITLE <br /> (D W PLOT PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P SE II ROUT INS PION PHAS I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426` Rev. . 1-74 � 11� ' .�'''I �a�,F1i 6/77 9M <br />