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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: #11601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' <br /> i <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 madein compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��I�r�a �' (n.jy%c� , CENSUS TRACT <br /> Owner's Name Cl FAA A N Phone -5076 <br /> Address City zf-&-,,gj_n'd <br /> Contractor's Name .��:�j� >J- - p:� .` License 790 o Phone <br /> z� <br /> TYPE OF WORK (Check) : NEW WELL/-T DEEPEN' /_/^RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 1­7 PUMP REPAIR PUMP REPLACEMT /7 <br /> Other { � EN <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 �F TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation �} <br /> Domestic/private ix ` Drilled Dia. of Well Casing <br /> Domestic/public .1' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection.. Rotary Type of Grout <br /> Disposal f, Other Other Information <br /> Geophysical f Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I r <br /> i Type 4of Primp t; . ,o- _. H.P. <br /> PUMP REPLACEMENT: /`/ !State Work Done $�a <br /> y vas <br /> PUMP .REPAIR: State=�W.ork�'D6neA.4�T)t) !1�.,7 ,p _. � �jc• / � _ •_ � T ___: <br /> DESTRUCTION OF WELL: We11 FDiamet r "�'' �v�s�. � �' Approximate:'.-- <br /> Depth <br /> Describe Material and Procedure j <br /> 4I 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 best of my knowledge and belief. I WILL CALL FOR A �GROUT .INSPECTION <br /> PRIOR TO GR TING AND 4 FI AL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED. BY .w ; DATE .� <br /> ADDITIONAL COMMENTS ' 7A7Z: <br /> PHASE ,II GRQUT INSPECTION PH&SV ZZI&INa INSPECTIQN <br /> INSPECTION BY DATE; INSPECTION BY DATE <br /> :; . <br /> IZ7 <br /> d <br /> H x1426 Rev. 1-74 2M <br />