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SAN JOAQUIN LOCAL HEALTH DISTRICTFOfi7OFFICEUSE: 1601 E. .Hazelton Ave. - Stockton, Calif. <br />Telephone: (209) 466-6781APPLICATIONFORWELLCONSTRUCTIONOR PUMP PERMIT Permit No. ;:g5- <br />THIS <br />6_ <br />THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedCompleteInTriplicate)Application is hereby made to the San Joaquin Local Health District for a permit to constructand/or install the work herein described. This application is made in compliance with San JoaquinCountyOrdinanceNo. 1862 and the Rules and Regulations of the San Joaquin Local Health District.JOB ADDRESS/LOCATION S <br />CENSUS TRACT <br />Owner's Nance <br />Phone <br />Address <br />City <br />Contractor's Name <br />icense # 4 Phone.-'2 Z <br />TYPE OF WORK (Check): NEW WELL/ DEEPEN -/_7 RECONDITION /'7 DESTRUCTION 1-7PUMPINSTALLATIONL-7 PUMP REPAIR L-7 PUMP REPLACEMENTOther <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY JSEWAGEDISPOSAL'IFELDCESSPOOL/SEEPAGE PIT OTHERPROPERTYLINE - PRIVATE IIOMESTIC WELL PUBLIC DOMESTIC WELLINTENDEDUSETYPEOFWELLIndustrialCONSTRUCTIONSPECIFICATIONSCableTool. Dia. of Well Excavation <br />Domestic/ <br />private Drilled Dia". of 4Fe11 CasingpublicDrivenIrrigationGaugeof. CasingGavelPackDepthofGrout SealCathodicProtectionRotaryTypeofGroutDisposalOtherOtherInformationGeophysical <br />Surface Seal Installed B <br />PUMP INSTALLATION: Contractor <br />Type of Pump <br />H.P. <br />PUMP REPLACEMENT: State Work Done <br />PUMP :REPAIR: State Work Done <br />ES•TRUCTION OF WELL: Well Diameter <br />Describe Material and Procedure <br />Approximate -Depth <br />hereby agree to comply with all laws and regulations of the an Joaquin LocWl Health DistrictcndtheStateofCaliforniapertainingtoorregulatingwell "construction. Within FIFTEEN DAYSaftercompletionofmyworkonanewwell, I will furnish the San Joaquin Local. Health DistrictFELLDRILLERSREPORTofthewellandnotifythembeforeputtingthe..well in use.... The abovereformationistruetothe,best -of my..knowledge and belief. I WILL CALL FOR ARIORTOGOUTINANFINALNSCTI GROUT INSPECTION <br />IGNED f Y TITLE <br />DRAW PLOT PLAN ON REVERSE SIDE <br />HASE I FOR DEPARTMENT USE ONLY <br />PPLICATION ACCEPTED BY <br />DDITIONAL COMMENTS: y DATE Av7 aA <br />PHASE IT GROUT INSPECTION <br />A— <br />LISPECTION BY PHASE III FINAL INSPECTIONDATEINSPECTIONBYDATE x <br />E'H 1426 Rev. 1-74 r- c. •sr .,,,R