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SAN JOAQUIN LOCAL HEALTH. DISTRICT 9,4 <br /> 601 USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �F. <br /> Telephone: (20'W 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1- - <br /> r { <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,��-,2#_7,9 <br /> (Complete In Triplicate) C>_?a yZ <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 r <br /> SUS TRACT <br /> Owner's Name <br /> 2c Phone <br /> Address <br /> City <br /> Contractor's Name �- <br /> License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT1_7 �"��.•,3i ® '. <br /> f 'Other / / <br /> } <br /> f t <br /> DISTANCE TO NEAREST: SEPTIC TANK dn,f SEWER LINES PIT PRIVY .. <br /> SEWAGE 'DISPOSALrFIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINED PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _2W4 •. _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIF CATIONS O <br /> Industrial t Cable Tool Dia, of Well Excavation a � <br /> Domestic/private i Drilled Dia'. of Well Casing <br /> Domestic/public t Driven Gauge of Casing 1 46 rn <br /> _ Irrigation ! Gravel Pack Depth of Grout Seal i <br /> Cathodic Protection 1. Rotary Type of Grout <br /> Disposal f Other .�M,�c..�' <br /> Other ..Information E <br /> Geophysical ._ --- �—Surf-ace'' Seal-InstalleA-B : � <br /> PUMP INSTALLATION: Contractor <br /> is Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ' . <br /> PUMP .REPAIR: "` �„ � '.. f.. <br /> - /�/ S�ate�Work Done <br /> / f <br /> DESTRUCTION OF. WELL: Well Diameter <br /> Approximate Depth ' <br /> 1 Describe Material -and Procedure <br /> f <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 regulat•ing,.we'il -'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 hem before putting the .well in use. The above <br /> information is true to he•.best f k cige,and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG T D FINAL I P I <br /> SIGNED vim' - TITLE- <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATEw" 171-7 <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTI N P /FIN INSPECTION <br /> INSPECTION BY ATE 2 INSPECTION BY ' , DATE Z �7 <br /> A % E H 1426 Vol v . 1-74I--¢- n� U► G ,� ��.. f/ ! �/ '� 1177: " 2M <br />