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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 11601 E. Hazelton Ave. , Stockton, Calif. I <br /> 1 Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, - � -� <br /> T I 1 <br /> THIS TERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 5?_? <br /> (Complete In Triplicate) <br /> Application 'is`Nereby made to the San Joaquin Local Health District for a permit to construct <br /> I <br /> and/or install the work herein described. This application is made in compliance with San Joaquin I <br /> County Ordinance No. .1$62 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION II <br /> r► � CENSUS TRACT <br /> Owner's Name © ey �IS� Phone �� '-7,2262 <br /> IM <br /> Address <br /> City � <br /> rr <br /> Contractor's Name ?� /I _ License # 0790/QPhane� r4;Qj <br /> II <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /-J DESTRUCTION /-71 <br /> PUMP INSTALLAT_,ION / / PUMP REPAIR ', PUMP REPLACEMENT ' /7. 'I <br /> Other'� <br /> DISTANCE ,TO--NEARES.T.: q,SEPTTANK II SEWER LINES PIT PRIVY <br /> -" � IC SEWAGEkDISPOSAL' FIELD CESSPOOL/SEEPAGE PIT OTHER �+ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED 'USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS *i <br /> Industrial 11 Cable Tool Dia, of Well Excavation <br /> Domestic/private SII, Drilled Dia, of Well Casing <br /> Domestic/public GM Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I! Rotary Type of Grout <br /> kd <br /> Disposal aher Other Information I <br /> Geophysical I` Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor/ "l <br /> 'I -- <br /> Type of Pump- , H.P. <br /> PUMP REPLACEMENT: / / State +Work Done <br /> PUMP REPAIR: State Work Done A <br /> N.DESTRUCTION OF WELL: Well Diamet r pVroximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and.,re,gplat.ions of the San Joaquin Local Health District <br /> and the State of California pertaining to or;..regulating+.we11 '0bdsitruction:)s;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 these'��foxe�,puttin�g'thee wellin use. The above <br /> information is ,true to the best of. my jknowledge.,and -belief.•O I WILL CALL`.FOR`1?: GROUT INSPECTION <br />,PRIOR TO GROU^ING AND A7AINAL INSPECTION. t <br /> SIGNED 3 ; F r TITLE <br /> III 3 +.1, (DRAW PLOT PLAN ON REVERSE SIDE) <br /> , j FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY�'% _�1.. `� '_,;' + /P DATE. <br /> ADDITIONAL COMMENTS', <br /> PHASE II G OUT INSPECTION - TE I I/F NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BDATE <br /> 2M <br /> E H 1426 Rev. "1=74, ! i f7 71 ' <br />