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C SAN JOAQUIN LOCAL HEALTH DISTRICT (, <br /> FO1 <br /> ,OFFICE USE: ` <br /> - 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> * Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L-_414 <br /> THIS PERMIT EXPIRES 1 YEAR=FROM DATE ISSUED Date Issued _.w_7 <br /> (Complete In Triplicate) <br /> Application is hereby made tolthe 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 andlthe Rules and Regulations of the San Joaquin Local. Health District. . <br /> i R <br /> JOB ADDRESS/LOCATION , , r "" CENSUS TRACT <br /> Owner's Name Phone <br /> Address S- w: City <br /> Contractor's Name � <br /> License # 11 —_—Phone �G 76_,24 <br /> 4 i <br /> TYPE OF WORK (Check): NEW WELL -/_7 DEEPEN -/-7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / PUMP REPAIR /JR7 PUMP REPLACEMENT / f <br /> Other / / '--- <br /> I! <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 CONSTRUCTION SPECIFICATIONS 3Zj <br /> Industrial � - t. Cable Tool Dia. of Well Excavation <br /> Domestic/private + Drilled Dia. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> ! Cathodic Protection i Rotary Type of Grout <br /> i Disposal i Other Other Information <br /> Geophysical u. Surface S ._ <br /> eal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> x Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: State Work Donencf- 4 ,WC, ��,'e <br /> ' i <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material, and Procedure <br /> I hereby agree to comply with'al1 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 thewell in use... The above <br /> information is true to the best of my,.know d ean elief. I WILL CALL FOR A GROUT INSPECTION �. <br /> PRIOR. TO ING A FINAL I P <br /> SIGNED LE <br /> D PLOT PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: F <br /> PHASE II GROUT INSPECTION PHAS&I I AL INSPECTION + <br /> INSPECTION BY DATE INSPECTION BY <br /> E H 1426 Rev. 1-74 -74 9M <br />