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-�YSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF� 0 ' '1E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit`No. , 1,2VO <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED Date Issued' J <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 Joaquir <br /> County Ordinance .,No. <br /> No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> wig .--.,..,-. <br /> JOB ADDRESS%LOCAT ONI <br /> CENSUS TRACT <br /> 1" <br /> Owner's Name Phone ' <br /> I <br /> Address <br /> pity . . <br /> Contractor's Name ✓v�rra <br /> b License # /Ahone 7,-7471d <br /> TYPE OF WORK (Check): NEW WELL /?. DEEPENI-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR-/3� PUMP REPLACEMENT f7 <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation <br /> 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 Rotary Type of .Groat <br /> Disposal 4 d Other Other Information ' ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br />` <br /> Type of Pump _ *,..- -p..-, h, - H.P. " / <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP '.REPAIR: / / :State Work Done <br /> DESTRUCTION OF WELL: Well. 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 /> a 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 /> informatio s true to the-best--o - k wle a and belief. I WILL CALL FOR A GROUT INSPECTION <br />' PRIOR TOG i TING " D A PIN& _ <br /> IkSVZCTFINAL_ <br /> TITLE <br /> MPL'E <br /> RSE SIDE""TMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED B DATE _ <br /> ADDITIONAL'COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY i DATE <br /> E H ,1426 - Rev_ .- 1-74 - -- - i' 1175 2M <br />