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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OF CE USE: 1601 E. Hazelton Ave. ,,- Stockton, Calif. <br /> Telephone :- P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PER141T Permit No. �a <br /> _-_ THIS. PERMIT EXPIRES .1 YEAR FROM DATE ISSUED <br /> �r Daae Issued 51-G/"7Q <br /> �.2�f_4Qfw "'l v14 tS_E r4�sE (Complete In Triplicate) ( Q� / <br /> i Application is hereby made to the San Joaquin Local Health District for a permit to -OS <br /> construct <br /> and/or install the work herein described. This application is i' �Y Ordinance No. made in compliance with San Joaquin <br /> and <br /> } 786 th a Replations of the- San Joaquin Local Health District. <br /> �L/Jl4iSG - - <br /> JOB ADDRESS/LOCATION <br /> st CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address C / <br /> �1 � �UUrS� aura City roll" d epe/t . <br /> Contractor's Name ,f <br /> License # !yam ? _ Phone1-76 <br /> # _ <br /> oil <br /> TYPE OF WORK (Check) : NEW-WELL / DEEPEN I I RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /X-/ PUMP REPAIR / / PUMP. REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK _ <br /> SEWER LINES 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 <br /> _ CONSTRUCTION SPECIFICAIndustrial Cable Tool Dia. of Well'Excavat on TIONS <br /> Domestic/private I Drilled Dia. of Well. Casing \` <br /> Domestic/public I 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"B : <br />.PUMP INSTALLATION: Contractor - <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .�; <br /> State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter ^ <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dis <br /> and the State of California petrict <br /> nrtaining to or regulating well construction. .Within FIFTEEN DAYS <br /> after completion of my work oa new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we11 and notify them before putting .the. well in use. . The above <br /> information is true to the best of. m knowledg d belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING AND A FINAL INS CT ' <br /> S I GNE D " <br /> . ITLE _Ped,J. <br /> C W PLOT PLAN ON.R RISE SIDE) <br /> PHASE I, <br /> a FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/F NAL INSPECTION y <br /> INSPECTION BY DATE INSPECTION By <br /> DATE <br /> E H 1426 Rev. • 1--74 0�`l7 One <br />