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SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED <br /> LOBiOFFIC3; USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <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) 2yl &0— 0 1(oc, <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�z 1 C �ftiCEN US TRACT <br /> Owner's Name Phone / <br /> 6-:-7/_q <br /> Address /y 2l rqbn�, st city <br /> Contractor's Name License # � D�;'!3 Phone t� — (1 <br /> TYPE OF WORK (Check): NEW WELL IF0, DEEPEN 7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT f7 <br /> Other J7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' <br /> `f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL m <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 /> _j/_ 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 ti <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> m <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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 qROUTING AN A INAL INS CTIO . <br /> SIGNED ,. TLE <br /> (DRAW T PLAN ON REV RTE SIDE <br /> APARTMENT U E ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B ADATE 10 z� - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PWA.Z1TtjtfINAL INSPECTION <br /> INSPECTION BY P4TE INSPECTION BY DATE <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />