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SAN JOAQUIN LOCAL HEALTH D'ISTRIC'T v 4/ <br /> rOF OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR 'WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7f- <br /> ,2,20 <br /> — THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued' - /J <br /> is (Complete In Triplicate) <br /> i Application is hereby made to the San Joaquin Local. liealth 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. 1.862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' 4L9 p f Li A_ aCr,•��vJ CENSUS TRACT <br /> Owner's Name ,� Q 'gz- a ,.f 2,.- Phone <br /> Address S►u� - �a.`c�a,� p City <br /> 4 Contractor's Name t License #/ A-_? , Phone <br /> TYPE OF WORK (Check) : kW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR /}r/ PUMP REPLACEMENT <br /> O Cher <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATL DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL_ CONSTRUCTION SPECIFICATIONS G <br /> X Industrial Cable Tool Dia. of Well Excavation <br /> _> Domestic/private: Drilled Dia. of Well Casing <br /> l Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal J <br /> Cathodic Protection Rotary Type of Grout T <br /> Disposal Other Other Information <br /> s <br /> Geophysical. Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor e <br /> Type .of Pumpr H.P. Zr <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with a).). 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 of my know ed e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR UTING AND A FINAL I PE T. <br /> SIGNED TITLE / �P <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY �r,O DATE oZ l O <br /> ADDITIONAL COt-1NENTS: _ <br /> PHASE II_ OUT INSPECTION PHA E /F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ! 0/77 _ 2t, <br /> E 11 1426 Rev. - I-74 <br />