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p� k <br /> 1/3t4e 4 242eL� SAN JOAQUIN` LOCAL HEALTH DISTRICT <br /> FOR:OE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephon6: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��� <br /> g THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued 6-L8-2,6 <br /> (Complete In Triplicate) . <br /> k Application is hereby mad itlo 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 -Joaquii <br /> County Ordinance No. 1662 olid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/.LOCATION Z. �G�7"�f'u„ k CENSUS TRACT <br /> Owners Name <br /> + v d=A2L <br /> i � Phone <br /> Address p?t . rX!'d � 4 CityJ`� <br /> Contractor's Name c� F +r� License #/„�dad Phone <br /> TYPE OF WORK (Check): NEW WELL -/7 DEEPEN '/7 RECONDITION."/ 7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /fir/ PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other <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 kTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �c Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation : Gravel. Pack Depth of Grout Seal <br /> Cathodic Protection {'1 Rotary f Type of Grout <br /> I Disposal Other Other Information ' <br /> Geophysical ' r Surface Seal Installed B - <br /> I PUMP INSTALLATION: Contractor / ► � <br /> Type .of Pump f H.P. / <br /> PUMP REPLACEMENT /_7 State Work Done P <br /> PUMP :REPAIR:= _ / /- State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter � " a Approximate Depth <br /> Describe_ Material amd Procedures <br /> I hereby agree to comply with.-all laws and regulations of the San Joaquin Local Health District <br /> and the State of California'.tpertaining to or regulating well•construction. Within FIFTEEN DAYS <br /> after completion of my work'on a new well,11I 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-bestof knowledge-•and belief. I WILL CALL FOR ,A 'GROUT INSPECTI <br /> 11 <br /> PRIOR TO GROU TNG AND A.FINAL INS EMM i <br /> F SIGNED TITLE _ , <br /> DMAV PLOT PLAN ON ERSE SIDE <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY <br /> DATE - <br /> ADDITIONAL COMMENTS: G <br /> PHASE II UT INSPECTION PHASE I .4(VNAL SPECTION <br /> INSPECTION BY DATE INSPECTION BY TE 2- <br /> E <br /> . » <br /> 1426 Rev. l-74 h/75 2M <br />