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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FD$0 ICHF E E. / 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) <br /> Application is hereby made to the Son Joaquin Local Iica?.th 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 �3 ,3.3 ,T, '"T„� . �^ CENSUS TRACT <br /> Owner's Name 'F�lj ac�.�la Phone <br /> Address 733, ��(.r /�gr, City <br /> Contractor's Name -+ r./ License G / 1 '"Phone <br /> z <br /> TYPE OF WORK (Check.): NEW WELL IV7 DEEPEN /7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /LP' <br /> Other <br /> ,( DISTANCE TO NEAREui: SEPTIC TANK SEWER LINES - °IT PRIVY <br /> <, SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> v <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELL -- PUBLIC DOMESTIC WELL <br /> ?) INTENDED USE TYPE OP WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial Cable Tool Dia. of Well Excavation Lj <br /> _4e 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 Pp: <br /> ' .S <br /> v PUMP INSTALLATION. Contractor <br /> Type of Pump i m .:�.�r . %E, N.P. <br /> PUMP REPLACEMENT: mak/ State Work Done <br /> U <br /> PUMP •.REPAIR: / / State Work Done <br /> DES-TRUCTIUN OF WELL: Welt Diameter - Approximate Depth <br /> b Describe Material and Procedure <br /> .5 I hereby agree to comply with all laws mrd regulations of the San Joaquin Local Health District <br /> i? and the State of California pertaining ^o 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 /> .L' WELL DRILLERS REPORT of the well and no them before nutting the well in use. The above <br /> '? information is true to the best-of.my k .owledge and belief. I WILL CA-11 FOR A GROUT INSPECTION <br /> PRIOR TO TINC JD A FINAL, IN <br /> SPE I )) <br /> SIGNS - -�� ; ✓ 4-��/TITLE '/"/F, (' <br /> "PLOT PLAN ONI,SEVERSE SIDS <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION :-CEPTED BY� , . - DATE. <br /> ADDITIONAL COMMENTS: :T- <br /> PHASE ITGROUT IN.".PECTION PHASE IFTN.AL INSPECTION <br /> INSPECTION BY DATE INSPECTION by i..,o(� DATEis- ' -7) <br /> E H 1426 Rev. 1-74 'tt9'7r"21v <br />