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M;4& a SAN JOAQUIN LOCAL HEALTH DISTRICT - -- <br /> ' FOEtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> + ' Telephone: (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made t6 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 andlthe Rules and Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION C, ho,�I/ a <br /> -- / �-- CENSUS TRACT <br /> Owner's Name 7,0 G ,,.g' Phone <br /> Address t `S' City <br /> Contractor's Name y License #,6&7y Phone _f a. 47.,E <br /> j <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN ,/_7 RECONDITION //_7_ DESTRUCTION <br /> PUMP INSTALLATION /_/ .PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /f <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DQMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private a Drilled Dia. of Well Casing <br /> /Public j <br /> Domestic Driven Gauge of Casing <br /> _Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodit Protection Rotary Type of Grout <br /> ► Disposal Other Other Information <br /> Geophysical.. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor e// <br /> Type of Pump6 k H.P. <br /> Urf <br /> PUMP REPLACEMENT: / / State Work Done jl <br /> F <br /> PUMP .REPAIR: State Work Done r <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Desci e Material- hdWPiocedure P <br /> I hereby Agree=comply with-611_lawe,'and regulations of the San Joaquin Local Health District <br /> and the State,,,of,,Calif.ornia:pertaining to or regula1:ing we 11 <br /> construction. Within FIFTEEN DAYS <br /> after completion of rays work. on anewwell, Iwili*furnish-the San Joaquin Local Health District a <br /> WELL DRILLERS,REPORT of the.well arid,.-notifyjthem abefore putting the .,well in use.. The above <br /> information is true ta'­the best of m wl <br /> y edge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIQR TQ''G OUTING.AND�AIFINAL ' •N SPS I ° 4 <br /> LSIGNE2D ITLE <br /> RAW T 'PLAN ON= RSE SIDE <br /> c ,;FOR�I3EPARTMENT USE ONLY <br /> PHASE-.,I', <br /> APPLICATION"ACCEPTED B21N_ <br /> DATE l - <br /> ADDITIONAL COMMENTS. �`: � A <br /> PHASE II-GROUT INSPECTION <br /> PHASE xI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 _7� i <br />