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co Htp SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE+OF ICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: '(209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2�4_ ,57/ �, <br /> THIS PERMIT EXTIRES,1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ,.. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to conbtruct <br /> and/or install the work, herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1.862 and. the Rules and, Regulations :,,of the San Joaquin Local Health District. <br /> JOS ADDRESS/LOCATION 4L� jr 2f�r!}� cENsus TRACT <br /> Owner's Name-- d ca.., r H -Q Phone <br /> Address - a D 6 r- �{ vis �-t' city ( <br /> Contractor's Name j7 <br /> a ; License Zone � <br /> I <br /> t41 <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /-7 _ <br /> S ' PUMP INSTALLATION / / PUMP REPAIR - PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i PIT PRIVY <br /> "'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ti PROPERTY LINE -- PRIVATE DOMESTIC WELL.— PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. ,of Well Excavation <br /> e-Domestic/private Drilled Dia. '!of Well Casing <br /> Domestic/public Driven Gauge of Casing `C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ' Cathodic Protection Rotary Typelof Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Instal3.ed By: <br /> 7. . .. 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1. H.P. �— <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / State Work Done <br /> y' <br /> 4 pES,TRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> ( Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I 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.knowleand-belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UNG AND A FINAL INSPE <br /> SIGNED .ITLE <br /> %. (D WT P ON REVERSE SIDE) <br /> zi R DEPARTMENT USE ONLY <br /> PHASE II �l a <br /> APPLICATION ACCEPTED BY `22 /DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> l77 <br /> 't E H 1426 Rev. 1-74 U 1-74 2M <br />