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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> O&:OFFICE USE; ' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �, 3Gt5`4J <br /> THIS PERMIT EXPIRES Z YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 Z,3Al _rQ Al <br /> /�, - CENSUS TRACT <br /> Owner's Name 4 4 440 L.6 S pq/e Q Phone <br /> Address a <br /> city ,Z° N, <br /> Contractor's Name <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL �/7 DEEPEN /"7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP IN§SIALAWN / / PYMP REPAIR- ( PUMP REPLACEMENT /? F� <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPO <br /> OL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVA 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 Grout <br /> Disposal Other Other Information <br /> Geophysical _ �_ Surface Seal Installed 'By: . . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ T � H.P, <br /> PUMP .REPLACEMENT: ]�/r State Work Done44 <br /> r' <br />?UMP :REPAIR: ?� <br /> / State Work Done <br /> IES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> End the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a j <br /> TELL DRILLERS REPORT of the well and notify them before putting.. the .well. in.use... .The above <br />.nformation is true to the,best -of my- knowledge and belief. I WILL CALL- FOR A 'GROUT INSPECTION <br /> RIOR TO U ING Amn A FI INSPECTION. . <br />'IGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIRE <br /> RASE i <br /> FOR DEPARTIaENT USE ONLY <br /> ---'�_ <br />?P IZ CATION ACCEPTED BY � �.- <br /> DDITIONAL COMMENTS e. DATE. Z <br /> PHASE II GROUT INSPECTION P E III F NAL INSPECTION <br /> NSPECTION BY DATE INSPECTION BY <br /> -- --_�. DATE _ .Z,��7s✓, <br /> E H 1426 -,. Rev. 1-74 <br />