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CID"t1p SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;4 ICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> + Telephone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,57-- <br /> THIS <br /> ,57=THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is 'hereby made to the Sant Joaquin Local -Health District for a permit to construct <br /> and/or install the work herein described. This appXication Is made in compliance with San Joaquii <br /> County Ordinance No. 1862 afid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r7A AA <br /> CENSUS TRACT <br /> Ownerts Name g ;,1xa <br /> Af Phone <br /> Address 1 D1� �"� Cit <br /> Contractor's Name 'A <br /> License # j .� ,Xhone Z <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION F7 T DESTRUCTION ./� <br /> PUMP INSTALLATION PUMP REPAIR/? PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE`DISPOSAL FIELD CESSP00L/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 L%j <br />` Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public �� Driven <br />((( Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> Disposal a Other , Other Information-,: <br /> Geophysical —"�—�- <br /> i __ - Surface. Seal Installed 'B : . . . <br /> PUMP INSTALLATION: Contractor , <br /> Type .of Pump <br /> H.P. <br /> '�►.� <br /> 1 PUMP REPLACEMENT: . AL/ State Work Done <br /> PUMP :REPAIR; <br /> /-7 State Work Done <br />€ DES-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with: all haws and regulations of the San Joaquin Local Health District <br /> 4 and the State of California pertaining to or regulating wellc <br /> after completion of my work on a new wellonstruction. Within FIFTEEN DAYS <br /> , I will furnish the San Joaquin Local Health District- a <br /> WELL DRILLERS REPORT of the well and not fy them before puttingthe -well in.use.—The above <br /> information is true to the bee f•my.. o ge nd belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING D A FINAL f SPE I <br /> ITLE e. <br /> FPLOT PLAN.ON ERSE SIDE— <br /> PHASE I <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: t , <br /> PHASE If GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATEw INSPECTION BY DATE /o <br /> E H 1426 Rev. �. <br /> 1-74� _-- <br />