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SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <br /> F0 OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ��L-- <br /> Telephone: (209) 466-6781 77���ye <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 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 �� � `jj '-�� Q CENSUS TRACT <br /> Owner's Name Phone <br /> Address city <br /> Contractor's Name License #` �.d Phone,:_ LXX, 74?Z <br /> i <br /> TYPE OF WORK (Check) : NEW, WELL / / DEEPEN/ / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /y/ PUMP REPLACEMENT <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 /> D6mestic/private Drilled Dia, of Well Casing \n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �U <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: ° I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. a <br /> PUMP REPLACEMENT: / / State Work Done !` <br /> PUMP .REPAIR: 5T State Work Done < /4d Ad 0044p <br /> DES,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 /> 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 ofn w dge an elief, I WILL CALF FOR A GROUT INSPECTION <br /> PRIOR TO - NG AND A FINAL INS ION. <br /> SIGNEDf'-- ITLE <br /> (D PL PLAN ON E SIDE) <br /> FOR 'PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE &4��,7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PH4AE,XIj INAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE 9 7 <br /> E H 1426 Rain_ � 1.-.7L� <br /> �,�7.7 _ 2M <br />