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SAN JOAQUIN LOCAL HEALTH DISTRICT �z � P�� P.� <br /> FOE�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. `' W4t' 4-- <br /> Telephone: (209) 466-6781 <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. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION {� 4P CENSUS TRACT <br /> Owner's Name 70, Phone <br /> Address �p City !h G� <br /> Contractora Namesd4a L.) So G/ . License # ±f.-r-7;J-0P"hone �d'l- 74 ^ <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /-7 DESTRUCTION 17 <br /> PUMP INSTALLATION /P7 PUMP REPAIR /-7 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 '`0 <br /> �. Industrial Cable Tool Dia. of Well Excavation 44, <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <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- BX: <br /> PUMP INSTALLATION: Contractor W 0 <br /> Type of Pump , g*P. <br /> PUMP REPLACEMENT: <br /> /-7 State Work Done <br /> PUMP '.REPAIR: Ig State Work Done 1�GIf _ ,�.- , <br /> ES-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,bestdaf my w dge a belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AN A FINAL I E IO <br /> SIGNED _ ITLE <br /> DRAVW PLOT PLAN ON Rl RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /���� <br /> APPLICATION ACCEPTED BY DATE Q <br /> ZZ <br /> ADDITIONAL COMMENTS: NX <br /> PHASE II GROUT INSPECTION PHAcA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE `2 <br /> E H 1425 Rev. 1-74 1-74 2M j <br /> -- - — - <br />