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r,111-Al <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT 1)�v 1I !►UGS '~`y <br /> s <br /> FOF 'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 3 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 3 f�L� <br /> 4 (Complete In Triplicate) . <br /> Application is hereby made to the San Joaquin Local Health District .for a permit to construct w <br /> ' and./or install th/W01 <br /> k herein described. This application is made. in compliance with San Joaquir <br /> County Ordinance 86 and the Rules and,Regulations. of the San Joaquin Local Health Aistric . <br /> as- 3�r� <br /> JOB ADDRESS/LOCAIKION CENSUS TRACT <br /> s - <br /> Owner's Name Q i.� Phone y <br /> �. Address ��. City <br /> i <br /> Contractor's Name �, License # C Phone 1� a <br /> �f <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO .NEAREST: SEPTIC TANK AX/ SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD � CESSPOOL/SEPAGEa.PLT OTHER �0 i <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL , PUBLIC DOMESTIC WELL' a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> {`Industrial Cable Tool Dia. of Well Excavation <br /> Cl.,, 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 ' !:Y. Other Other Information IA-LA 49J.01" <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: \Contractor <br /> Type of., Pump _ H.P. <br /> PUMP REPLACEMENT: / / ",,State Work Done �9 <br /> PUMP .REPAIR:--- -� /—/=L.-State-Work Don <br /> DESTRUCTION OF WELL: Well Diameter & vv�r�C2. t Approximate Depth <br /> Describe Material a d 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 c <br /> WELL DRILLERS REPORT of ,the -well. and notify them before putting the well in use... The above <br /> information is true to th_e best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1PRIOR TO GR TING AND AL INSPE TION, <br /> SIGNED TITLE <br /> td-PLCrT PLAN ON FRSE Si <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -:2", <br /> kk ADDITIONAL COMMENTS: , <br /> 4 PHAZ II GROUV INSPECTION PHAS IN INSPECTION ; <br /> Z7 P <br /> INSPECTION BY DATE '� 1�� 7t INSPECTION BX DATE j <br /> t E H 1, 2'6- Rev. - 1-74 Y <br />