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- SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE._Or510E USE: 1601 E. HazeltonAve: ,­Stockton, Calif. <br /> r : <br /> Tele hone <br /> p (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIkES l YEAR FROM DATE ISSUED Date Issued <br /> I (Complete 'In Triplicate) <br /> A <br /> pplication 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 /> ,70B ADDRESS/LOCATION Q QEt" ! k CENSUS TRACT <br /> ,. <br /> Owner's Name Phone /d im 7, Le <br /> i <br /> Address 2 y� <br /> City <br /> Contractor's Name <br /> License #48_L71/ Phone �{�d <br /> TYPE OF WORK (Check) : NEW WELL --DEEPTN `% RECONDITION /. / DESTRUCTION / 7 <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT �� <br /> Othergg/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL by 1 <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Cathodic Protection l Rotary Type T ln' <br /> of Grout <br /> Disposal i Other Other Information I`n <br /> Geophysical { Surface Seal Installed By: ' <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump --' H.P. <br /> PUMP REPLACEMENT: / / Sitate Work Done <br /> PUMP .REPAIR--: -17/ �:e-Sta°te Work Done -. <br /> DESTRUCTION OF 'WELL:- Well Diameter Approximate Depth <br /> Describe Material and Procedure p p <br /> . r <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 notify them before putting the well 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 FINALIINSPECTION. <br /> SIGNED (f p TITLE <br /> D W TLWT PLAN 'ON RE FRSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHASE II)i/FINAL II/FINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 D dFi2 /Z �� �o�, ,v i b ► <br />