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F 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFr.QF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued <br /> (Complete In Triplicate) <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 J'oaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> rR ✓i d. � <br /> JOB ADDRESS/LOCATION A � + CENSUS TRACT - <br /> , <br /> Owner's Name m/ 1 _ i d Phone ' <br /> Address Ala rt dsG city' _ 53� <br /> F �1 <br /> Contractor's Name pr. License # ` y,4 vj'Phone <br /> . 4 ^ tom <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN -/7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP[INSTALLATION / / PUMP REPAIR / Jf PUMP REPLACEMENT <br /> Other /_7 <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 /> w INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> W_�_bomestic/private Drilled Dia. of Well Casing (� <br /> =Domestic/public 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 'Iiistalled By:_ <br /> i C <br /> PUMP INSTALLATION: contractor(,- <br /> ! <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP REPAIR: State Work Done" r_04 I <br /> it <br /> DESTRUCTION OF WELL: ,. .WelV Diameter Approximate Depth <br /> Describe Material and Procedure <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 workton 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- o ed and bed ief. I WILL CALL 'FOR A GROUT INSPECTION <br /> PRIOR TO UTING'AND A FINAL IN IO <br /> SIGNED r Com(_ ITLE _ <br /> -(D§m nm PLAN ON ERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY s DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE 7 <br /> E H 1426 Rev: 1.-.74 �. � 4475 2M <br />