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- SAN JOAQUIN LOCAL HEALTH DISTRICT ( --- <br /> FO&+(OFFICE USE: <br /> l6fll E. Hazelton Ave. , Stockton, Calif. - -- <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/ - s-11V- <br /> (Complete In Triplicate) <br /> Application is hereby ;Wade 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 o;� 6 ecu_ CENSUS TRACT <br /> Owner's Name Phone o <br /> Address _ . <br /> City <br /> Contractor's Name License # X37 hone LAV 6—5 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLAT ON / / PUMP REPAIR / / PUMP P CEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 'LVNES PIT PRIVTJ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 4� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "ppv.. <br /> ndustrial Cable Tool Dia. of Well Excavation sV, <br /> Domestic/private Drilled Dia-. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing �?J <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �. <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done E <br /> "PUMP-.REPAIR;- "f .State Work Done _ -- — - - <br /> ES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby acomply with all laws and regulations of the San Joaquin Local Health District <br /> and the St of of Ca fornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after comp etion of work on a n well, I will furnish the San Joaquin Local Health District �a <br /> WELL DRIL ERS REPORT f th�11 <br /> fy them before putting. the..well in.use. The above <br /> informat n is t e the �aledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTING A F <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 T_,A „a <br />