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P+ <br /> SAN JbAQUIN LOCAL HEALTH DISTRICT <br /> A�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FO <br /> t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T /� <br /> �w <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 workherein described. This application: is made in compliance with San Joaquin i <br /> County Ordinance No.. 1862 and the Rules and Regulations of the.San Joaquin Local health District. ' <br /> JOB ADDRESS/LOCATION .:CENSUS TRACT <br /> Owner"s Name hl T Phone 3'3 7 ?/ <br /> AddieJ�s` City YOE E5 <br /> ly . <br /> License Phone r , <br /> Contractor s Name . A�MMa4� �'► — <br /> .:3 TYPE OF WORK (Check): NEW WELL /�-/" DEEPEN /7 RECONDITION %T DESTRUCTION �T/7 ` O> <br /> PUMP INSTALLATION /JiY PUMP REPAIR /� PUMP REPLACEMENT <br /> Other 1 I <br /> . DISTANCE TO,NEAREST: SEPTIC TANK r-* SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' <br /> PROPERTY LINE PRIVATE DOMESTIC WELL` - PUBLIC DOMESTIC WELL <br /> iINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS, <br /> I�'In-d�ustrial Cable Tool Dia;- of` Well Excavation <br /> c%Domestic/private Drilled Dia: of Well Casing <br /> 'S'Domestic/public Driven 'TGauge of Casing <br /> ��'Irrigatioa �Giave 1 Pack Depth-of Grout Seal �S <br /> . ; 1l-Cathodic Protection rotary - Type'of Grout - 0F A <br /> -Disposal Other ,. ,,Other Information <br /> i 1i Geophysical Surface. Seal Installed By: <br /> PUMP :INSTALLATION: Contractor <br /> li Type of Pump H.P. _ 3 <br /> _ 5 <br /> PUMP REPLACEMENT: / / <br /> State Work Done._. <br /> �PUMP ''REPAIR; L State Work Done <br /> l DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f I he 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'constructian. Within FIFTEEN DAYS <br /> s after completion of my work on a new well, I'will furnish the San Joaquin Local Health District <br /> WELLJ�DRILLERS REPORT of the well and notify them before putting.the..well in us <br /> 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 AND A FINAL INSPECTION. .TITLE <br /> SIGNED <br /> !� W PLOT PLAN ON REVERSE SIDE <br /> e DEPARTMENT USE ONLY <br /> PHASE I r <br /> i APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.: / <br /> it P II SP CT PHASENSPECTION <br /> r <br /> INSPECTION BY AT INSPECTION BY ATS_ <br /> ► 4 E, H 1426 Rev. I-74 � 1-74 2M <br />