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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -FOR-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;?f__/_,?�� <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 /> .TOB ADDRESS/LOCATION Q" CENSUS TRACT <br /> Owner's Namerlozo _,r'f Phones ` O - <br /> Address r City <br /> Contractor's Name License �,Z„5 Phone r <br /> _ A <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN /_% RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / AJ <br /> DISTANCE TO NEAREST: SEPTIC TANK Z,�!O SEWER LINES PIT PRIVY' `- <br /> v <br /> SEWAGE- DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /J <br /> ; -'{"pTMER Q <br /> ' PROPERTY LINE O�PRIVATE DOMESTIC WELLI�' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation /G " S <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/publicDriven -4 Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection - Rotary Type of Grout .� <br /> -DisposalOther - --- ) <br /> Other Information � - <br /> Geophysical Surface Seal Installed By: <br /> _. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 DATS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri�i a <br /> WELL DRILLERS REPORT the well and notify them before putting the well in use. The above <br /> information is t to the best of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR G ION <br /> /109 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> /11/7 <br /> ADDITIONAL COMMENTS: <br /> PHASE.I GROUT IN PECTI N PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE $ INSPECTION BY <br /> ��1 ,, <br /> 1 <br /> E :H., 1426 Rev. -74 \L � �, '`;�Y `� : 1 f.77 � 2M <br />