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SAN JOAQUIN LOCAL HEALTH DISTRICT A4'A 1-4, rom, !� 1cwws <br /> FOR OFFIC_�USE:~ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1y-�2 Z� <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 Joaquin; <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Goo, na h l-h 0-� T n e's I <br /> CENSUS TRACT J <br /> Owner's Name j / r <br /> .� Phone <br /> Address a O e <br /> City <br /> Contractor's Name 5 S , r- j License �E� phone� �L 1J s a <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <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 BELL _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br />_ Domestic/private J( Drilled Dia, of Well Casing 11 L <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of--Ctout Seal <br /> Cathodic Protection Rotary Type of Grout ', ' <br /> Disposal �12 4' <br /> -Other Information �Q � L� ,y n <br /> Geop s Other r- <br /> Surface Seal Installed B <br /> 71- <br /> PUMP INSTALLATION• '22� <br /> ontractor t y <br /> F <br /> Type of Pump -- <br /> . H.P, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> C 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 4- <br /> after completion of my work on a new well, I will furnish the San Joaquin. Local Health District a a <br /> BELL DRILLERS REPORT of the well and notify them before putting the well in use The above <br /> Lnformation is true to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br />;IGNED TITLE <br /> ---- (DRAW-P -PLAN�ON-REVSRSE-SI <br /> DE) •� -- . . <br /> FOR DEPARTMENT USE ONLY <br />'RASE I <br /> APPLICATION ACCEPTED BY DATE <br />,DDITIONAL COMMENTS <br /> P SE GROU NSPECTION PHASE I/FINAL INSPEC ION <br /> NSPECTION BY DATE INSPECTION BY <br /> E H 1426Rev. 1-74 r � . <br />