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a! <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: VZ1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (20.9) 466-6781 �� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued f <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4523 Parra St. CENSUS TRACT <br /> . { <br /> Owner's Name Stockton 'Unified School District - Phone 456-3911 <br /> Address <br /> 1149 N. E1 Dorado St. City Stockton <br /> _ <br /> Contractor's Name l a t�x,terj,ri eca <br /> License # �_ Phone _ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ .I DEEPEN / / RECONDITION /7 DESTRUC ON <br /> PUMP INSTALLATION I I PUMP REPAIR I / PUMP REPLAC _ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <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 fl <br /> Domestic/private Drilled Dia. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing w <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Other Information <br /> Disposal Other <br /> Surface Seal Installed By: <br /> Geophysical <br /> f PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> 4 PULP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure Fill with neat cement our ca over <br /> casiiYg 3 ft. below existing grade <br /> r <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 GRO ING AND A FINAL INSPECTION. Co-owner <br /> SIGNED TITLE <br /> DRAW-'P ! T' PLAN ON RE ERSE SID " � <br /> E ) ° <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: rD�, INSPECTION <br /> PHASE II GROU INSPECTION DATE %�_ 1-� - <br /> INSPECTION BY DATEINSPECTION B <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />