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SAN JOAQUIN LOCALHEALTHDISTRICT r <br /> FOR OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued4116171 <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 Vl Y"d ��~ CENSUS TRACT <br /> Owner's Name 1M cm_� _..._ r►_ Phone <br /> Address4zo City A4004-4 <br /> +� <br /> - � ,� � <br /> If <br /> Contractor's Name License # 37ione <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN :/-/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�/ PUMP REPLACEMENT 17 <br /> Other / J <br /> w .. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> I SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL : PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSY <br /> Industrial Cable Tool Dia. 'of Well Excavation \\ <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven <br /> Gauge, of_Y Casing <br /> Irrigation. iT " '� Grave i..Pack Depth of Grout Seal <br /> Cathodic Protection Rbtary( Type of Grout <br /> Disposal Other Other Information <br /> Geophysical rSurface Seal Installed By: <br /> , <br /> PUMP INSTALLATION; Contractor� C <br /> Type of Pump IiOl ,, H.P. <br /> i <br /> PUMP REPLACEMENT:- % / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> F th <br /> 1 <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 'I <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 m led a ief. I WILL CALL FOR A GROUT INSPECTION <br />'•PRIOR �ti"ROU NG AND A FIN <br /> SIGNE - TLE <br /> ( W <br /> PL2T 0 RE E SIDE) <br /> FQ9 DEPARTMENT USE ONLY <br /> PHASE I : ��++ <br /> APPLICATION ACCEPTED BY C•� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHAS /FINA INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY ATE j <br /> 1177: � 2M <br /> E H 1426 Rev. ]-74 } <br />