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SAN JOAQUIN LOCAL HEALTH DISTRICT "" <br /> FOR OFFICE USE: �i 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 CAr <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3tJ <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 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U -A-4 44& Rd eilnci�ln <br /> CENSUS TRACT <br /> Owner's Name Phone�7,1� , <br /> Address v„4, City <br /> Contractor's Name �n��, License 174 hone9�3 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION / _ <br /> / DESTRUCTION / _ <br /> PUMP INSTALLATION <br /> LT-1 REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEQ 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 /> Domestic/private rilled Dia, of Well Casing <br /> Domestic/public E]:��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: <br /> PUMP INSTALLATION: Contractor 0. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work r1, µ <br /> PUMP .REPAIR: State Work Done �G+�/� UW.��z L�,�7�-� <br /> pin fV'/F4G T� l /� •9 _ . - i <br /> DESTRUCTION OF WEL_L,.::,..,...Wel1�"D ame ��/� Approximate Depth 3 S <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 complet.ion 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 thewell 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 GROUTING AND A F NAL INSPECTION. <br /> SIGNED oc <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDtD <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY �ff Z7 77 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA$E, WjGROU,T INSPECTION PHAS II/F NAL INSPECTI N <br /> INSPECTION BY DATE .- •g S� INSPECTION BY DATE / <br /> E H 1426 r Rev. .7 b/77 2M <br /> - <br />