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�- '.- SAN JOAQUIN LOCAL HEALTH <br /> STRICT <br /> c <br /> FOF�'-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 'o V� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT E)TIRES 1 YEAR FROM DATE ISSUED. Date Issued AL E J1 <br /> / (Complete In Triplicate) x <br /> ;4 . Applicdtign' is hereby made to the San Joaquin Local Health Distiict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' <br /> CENSUS TRACT <br /> Owner's Name Phone 42SL 2/ <br /> Address _ Cit ' . <br /> 1 Contractor's NameLicense•.#- �• Phoney- , <br /> r / <br /> TYPE OF WORK., (Check),. NEW WELL .4 DEEPEN /7 RECONDITION /_7 DESTRUCTIONI/7 <br /> PUMP INSTALLATION /% PUMP REPAIR / PUMP REPLACEMENT 17Other <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 <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 P Other Other Information <br /> -Geophysical Surface Seal- Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Donee <br /> PUMP !REPAIR: ' <br /> l� State Work Done <br /> E&TRUCTION OF WELL: , Well_ Diameter w : Approximate Depth <br /> Describe Material, and Procedure <br /> II hekeby 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 'Completi.on of my work on a new'well ;,..; 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 GROUTING D A FINAL PECTION. <br /> ,SIGNED <br /> TITLE <br /> - ' =`- -R(i?RAW PLOT--PLAN-ON-REVERSE SIDE "- <br /> PHASE I FOR IMPARTMENT USE ONLY <br /> � _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> f P SE XkSAGUT INSPECTION PHAfiE IlLIKiNAL INSPECTION <br /> INSPECTION BY - DATE INSPECTION BY DATE <br /> E H 1426. '.,Rev. 1-74 /' 1-74 2M <br />