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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4b6-6:.7.83, ..,....._ : . . w.�..w. -®x�.•,,.. Yti _ ,. W� <br /> APPLICATION ,FOR,+WEt'f, CONS CTION OR PUMP. PERMIT „ Permit No. or- <br /> If <br /> THIS PERMIT EXPIRES 1 YEAR.PROM DATETSSUED Date Issued 1s�j6 <br /> (Complete In Triplicate).. :. <br /> Application is heraby trade to the San Joaquin Local Health District far ria permit to construct <br /> and/or install the work herein described.. This application is made in compliance p nce with San Joaquiti <br /> ICounty Ordinance No. 1862 arid, the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name s �- <br /> Phone <br /> 1 'Address J77g r <br /> 'City. .. <br /> Contractor's Name Ojr Licensee hone <br /> - �-�� <br /> i <br /> d TYPE OF WORK (Check): NEW. WELL,.jo DEEPEN '/? RECONDITION /? DESTRUCTION /j <br /> PUMP INSTALLATION PUMP REPAIR 7 PUMP REPLACEMENT. /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE11DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELT, CONSTRUCTION SPECIFICATIONS <br /> Industrial tamable Tool Dia. of Well Excavation <br /> Lam_ �mestic/private Drilled Dia. of Well Casing <br /> 47 <br /> Domestic/Public Driven Gauge of Casing r \ <br /> Irrigation 41 Gravel Pack- Depth of Grout Seal i �1 <br /> f Cathodic Protection Rotary <br /> Disposal OtherType of Grout <br /> { <br /> _ =Geophysical ; - Other Information j <br /> Surface Seal Installed ' <br /> t <br /> PUMP INSTALLATION <br /> Contractor <br /> Type .of Pump ' <br /> ;PUMP REPLACEMENT:. I - ; <br /> / / State Work Done � <br /> 1: UMPIMPAIR: / / State Work Done <br /> IDES-TRUCTION OF WELL: Well Diameter A r <br />! pp oxmate Depth <br /> c Describe Material and-Procedure <br /> 1 I <br /> I hereby agree to comply withr•all laws and regulations of the San Joaquin Lbcal Health District <br /> and the State of California pertaining to or regulating well `construetion. Within FIFTEEN DAYS <br /> after completion of my work ,oi 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 ink.use.. . The above <br /> information is true to the best.of my'.knowled•ge and belief. I WILL CALL ,FOR A GROUT INSPECTION. ' <br /> PRIOR TO GROU G D A�FINAL INSPE <br /> SIGNED, TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE f. <br /> .. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHAR II G OUT INSPECTION <br /> INSPECTION BY PHAS FI INSPECTION, <br /> DATE INSPECTION BY DATE- <br /> - E H 1426Rev. 1-74 <br /> .. - ►. i.���, <br />