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4 <br /> SAN JOAQUINsLOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> w (Complete In Triplicate) <br /> Application is 'hereby made toIthe 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 0 R; `� �e .,, ,z CENSUS TRACT <br /> Owner's Name ( p Ei- 46 ks Phone <br /> Address 0 <br /> CityAOL <br /> Contractor's Name }. License #36-7s-3- Phone JEff-3 yS"T� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 �. <br /> Other '/-7 <br /> I. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �-4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation :1 Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection i! Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical I Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contra c for 4,0VrkIC <br /> Type of Pump 7H.P. ftp i <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL:WELL- Well Diameter pp 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 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAI. INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY (� <br /> PHASE I DATE _ ��7? <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION , / PHASE I/FIN INSPECT ON ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br />' F H IL26 Paw1-74 <br />