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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICE USE: 0 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (2,09)'t4S6--6781 <br /> 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 Aereby 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. 1.862 and the Rules and Regulations of the San' Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION # F CENSUS TRACT <br /> Owner's Namecozy C- Phone <br /> Address ,.�� <br /> city <br /> 9S-z as�- <br /> Contractor's Name License It Phone <br /> TYPE OF WORK (Check) : Ngo.-.�..�.. --�.�-�- <br /> ( W WELL '/ / EEPEN / RECONDITION /_/ DESTRUCTION /_7 w <br /> PUMP INS TALLAT UMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES !+ ; PIT PRIVY s y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT/_4_aL+--i PIT/_4_a+-- OTHER <br /> PROPERTY LINF/ -'*RIVATE DOMESTIC WELL L52PITBLIC DOMESTIC WELL <br /> INTENDED USE j TYPE OF WELL CONSTRUCTION 'SPECIFICATIONS <br /> IndustrialCable Tool Dia. 'of We11 Excavation ��q <br /> Domestic/private ; Drilled Dia. of ,Well Casing V " <br /> Domestic/public I Driven Gauge of Casing; <br /> Irrigation Gravel Pack Depth,of Grout' -,:Seal �--- <br /> Cathodic Protection! Rotary Type of Grout' <br /> Disposal i� <br /> Other , . ..Other Informations <br /> Geophysical 4' R Surface Seal Installed B k <br /> PUMP INSTALLATION. Contractor <br /> f <br /> Type of Pump H.P. 7i. <br /> PUMP REPLACEMENT: .- / / State Work Donee <br /> PUMP -REPAIR: R _ - _ / % State,Work Done _ <br />)ES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I� <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health bistrict <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 Ldcal Health District a <br /> 4ELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> Information is true to the bes of y nowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR T UTING FDA F AL S '�C 0 <br /> SIGNED TITLE Kv <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br />?RASE Ia !' FOR DEPARTMENT USE ONLY <br /> ` p% <br /> .i ' <br /> PLICATION'.`ACCEPT.EB BY',N`%1�'� DATE <br /> ADDITIONAL COMMENTS-. <br /> PHASE II;GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY' ,..,,, .--DATE INSPECTION BY -.4WDATE t_ <br /> :i <br /> tAl-W 1-49174t 1"AZI( <br /> 1127 <br /> E H 1426 Rev. 1-74 � (��%¢'�cl� ?M � <br />