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• � 3 <br /> SAlI JOAQUIN 'LOCAL HEALTH DISTRICT ; <br /> FOH OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELI'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ge,7Z_,�J <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 /,fQ A `]' ~ < CENSUS TRACT <br /> Owner's Name 114 o o r, Phone ?j z <br /> 'r <br /> AddressW <br /> City Xr7`0 pe--,. <br /> Contractor's Name U&Iyet7fg4 License # / Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION f / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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 (A <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 By: <br /> PUMP INSTALLATION: Contractor /L....'1/n0s�QL 1�& 15( XCI nil <br /> Type of Pump H.P. Z <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 all laws and regulations of the San Joaquin Vocal 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE h FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE - � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P /F AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 7 E H 1426 Rev. • 1-74_ <br /> b/77 . 2m <br />