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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR - FP ZCE Tj$E: X601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR,WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75'"r..:�il a v <br /> THIS PERMIT EXPIRES -l` XEAR FROM DATE ISSUED Date Issued - <br /> a I (Complete In Triplicate) s <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/LOCATIONl <br /> . /a �,.i 1 d!'.f � sJ�s d.,p CENSUS TRACT <br /> .bV11111 <br /> Owner's Name , - <br /> i Phone <br /> Address �, v <br /> ' Cityg- <br /> Contractor's Name <br /> License # 110 2one V4 36, 6"/"��� <br /> TYPE OF WORK (Check): NEW WELL '/7 DEEPEN'/? RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 0C/ PUMP REPLACEMENT �f <br /> Other'l/ / <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER LINES . ET IVY <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 I Cable Tool Dia. of Well Excavation <br /> Domestic/private -i Drilled Dia. of Well Casing i <br /> - -.Domestic/public. Driven Gauge of Casin <br /> g <br /> ZS Ir= ggtion�Y u_ . <br /> -Gravel-Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal: Other Other Information, <br /> —Ge.ophysical: <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: e Contractor <br /> Type of Pump H.P. r_ <br /> _ ��� o lJ1 <br /> PUMP REPLACEMENT: r / / State Work Done <br /> PUMP 'REPAIR: State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter " <br /> i <br /> Describe Material and ProcedureApproximate Depth <br /> ----�-- <br /> I hereby agree to comply with -all Saws 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 /> PRIOinforR <br /> O-QRtion is true % the best. y.kn wl ge a belief. I WILL CALL FOR A 'GROUT .INSPECTION t <br /> PRIOR UTTNG D A FINAL 0 <br /> SIGNED , TITLE - <br /> D W PLOT PLAN ON FRSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br />�'—'L TION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 01.1— <br /> PHAS TI GROUT I PECTION P SE FINAL INSPECTION <br /> INSPECTION BY _ _ DATE ; INSPECTION BY DATE 6- <br /> E H 1426 Rev. 1-74 <br />