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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR <br /> USE: -160I.- E. Hazelton. Ave. , Stockton, Calif. <br /> ! Tele hone;p (209) 465--67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Q� <br /> f <br /> THIS PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> } .(Complete In Triplicate) <br /> Application is hereby made to the Sat: Joaquin Local Health District for a permit to construct <br /> and/or install the .work herein described.: Thisapplication is made in compliance with San Joaquin <br /> County Ordinance`No—1862 aAd the Rules and Regula <br /> tions :of. ihe San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONR, r <br /> - - CENSUS TRACT <br /> !r ;�' ht3 � � -yea •.�, _ p .G.= ` <br /> Owner's Name <br /> Phone <br /> ' Address 7 S' City VISA lr4z <br />. �� <br /> Contractor's..Name License # 7 Thane y -2476 <br />', TYPE OF WORK ,(Check): NEW WELL -F7 DEEPEN _. RECONDITION /.7 : DESTRUCTION <br /> PUMP4�INSTALLATI0N ��/ PUMP REPAIR /� PUMP REPLACEMENTrT <br /> Other /7 <br /> i Y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT— <br /> 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 /> 1 „j!& Domestic/private s Drilled Dia. of Well Casing <br /> !�._.._. Domestic/public : Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth—of—Grout Seal <br /> Cathodic Protection r,.1.. Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysics] 'Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor <br /> Type of PumpILI H.P. <br /> # UJI <br /> PUMP REPLACEMENT: State Work Done ^ <br /> PUMP .REPAIR: L-7tate Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ! <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 motifthmm before <br /> Y putting., the..well in use.. The above <br /> informa. io is true to the•best y. dge belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR 3TING D A FINAL I E <br /> SIGNS ' ITLE <br /> . W P T PLAN ON WERSE SIDE <br /> PHASE I <br /> R P9PARTMENT E ONL + <br /> ; <br /> APPLICATION ACCEPTED BY . - Ti. <br /> ADDITIONAL COMMENTS: ? <br /> k PHASE II gKoUT P TI P NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATj.�c� <br /> E H 1426 _ . Rev. I-74 <br /> :: 1_7A Sur <br />