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�i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F:F:0�r,_ 0,FF'10E USE: ' 1601 E. Hazelton Ave.. , ,Stockton, Calif. <br /> G Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermitNo. � <br /> i� <br /> THIS -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3� <br /> I� (Complete_. In Triplicate) <br /> Application is Aereby 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 011sp CENSUS TRACT <br /> OwnerIs NameP� <br /> 7�d <br /> n <br /> 11VIV �-+- �Pt <br /> WtL"Lll l.'1"ILVY111CL <br /> A6/ilYtrC`t C7iY5c��� �rurvr•ri�a'rn�Lr- irvvr <br /> VNT�r n�rnin�+ <br /> REPLIIACEMENT❑ ` <br /> I DISTANCE TO NEAREST:, Septic Tank Sewer Lines` Pit Privy <br /> Contralctor's Name License # %'Phoney <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / ,/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / J PUMP REPAIR /W/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic <br /> 1 /private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> f irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic'Protection Rotary Type of Grout <br /> I Disposal Other Other Information i <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> 'Type of PumpcH.P. <br /> PUMP REPLACEMENT: / / "State Work :Done �- ' <br /> PUMP .REPAIR: /g{/ State Work Done _ e t <br />)ES•TRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure <br /> L hereby agree to comply with all Laws and regulations of the San Joaquin Local. Health, bisirict <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after Jompletion of my work on a new well, I will furnish the San Joaquin Local Health District' 4 I <br /> WELL DRILLERS REPORT of the well and notify diem before putting. the..well in use. The above <br /> information is true to the best of kno ed d belief. . I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GAO TING AND A FINAL PE I N <br /> SIGNED tr ITLE�&V4 ,c�!"' I� <br /> +I. _ (DPW-PLOT PLAN ON 'ERSE SIDE) <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A19 DATE <br /> 4DDITIONAL COMMENTS: <br /> PHASE II GROUT' INSPECI'ION PHASE ITIIFYNAL INSPECTIO <br /> INSPECTION BY DATES INSPECTION BY DATE <br /> Akl <br /> E Hi1426 Rev. I-74 - <br />