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'old SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF,-.Ol I'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i-?THIfS PERMIT EXPIRES 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 construe <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District: <br /> � CENSUS TRACT <br /> JOB ADDRESS/LOCATIONZY . ...... <br /> Owner's Name [1 Q Phone <br /> i <br /> �^ S City Ise <br /> Address <br /> Contractor's Name Allr <br /> ! License # �� 6 Phon� "3 e <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /t;---i3ESTRUCTION /— € , <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENTIr � .i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> F� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PUBLIC DOMESTIC WELL <br /> t yPRIVATE DOMESTIC WELL CONSTRUCTION SPECIFICATIONS <br /> :INTENDED USE TYPE OF WELL — <br /> Cw Industrial —/Cable Too] Dia. of Well Excavation <br /> " -'Domestic/privateDrzl-led Dia. of Well Casing - <br /> r a <br /> Domestic/public Driven T' '"-.Gauge -of`Casing - <br /> . Irrigation Gravel Pack', Depth 'of- Grout Seal <br /> Cathodic Protection Rotary t Type of Grout { <br /> Disposal <br /> Other t Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H..P. [ <br /> PUMP: REPLACEMENT: / / State Work Done E� <br /> -PUMP REPAIR• / / . State Work Done <br /> j <br /> DES-TRUCTION• Approximate Depth WELL: Well Diameter _ <br /> Describe Material and Procedure f� <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 DAYtrj <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 thewell in use.. The above <br /> e to the best of m GROUT INSPECTION <br /> information is true Y knowledge and belief. I WILL CALL FOR A <br /> PRIOR TO GROUTIN-C,AND A 94NAL IN ECT N.- . L <br /> k SIGNED , ; TITLE <br /> (DRAW,PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> PHASE i DATE �S <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION 'F <br /> r INSPECTION BY DATE 1NSPECTION YT _ DATE/f <br /> ..P <br /> '4 �r, . 6/77 _ 2M . <br /> ' F H 1426 Rev. • -74 � `l!" �" <br /> _ <br />