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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE,OFFICE USE: 1.601 E. Hazelton Ave: ,''Stockton, Calif. �� 7S yfel� <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .. : , Dater Issued .- <br /> (Complete In Triplicate) s . .; <br /> Applicafton is hereby`mada^ to the Stan Joaquin Local Health District, far a permit topconatruct <br /> and/or install the work herein described. 'This a applicatiOn "19 made in. compliance with Sari Joaquii <br /> County Ordinance No': 1862 '`iha the Mules and Regulations of the San;Jaaquin',Local^Health District. <br /> JOB ADDRESS/LOCATION9�'r " �,, <br /> .�� ^-s -o „_...�...��� .CENSUS TRACT <br /> n u <br /> Owner's Name Phoa9 <br /> I Address: Ica City <br /> Contractor's NameLicense Phatie` --� <br /> 4 <br /> TYPE OF WORK (Check): NEW WELL--WDEEP /? RECONDITION ,/'7 - DESTRUCTION <br /> PUMP INSTAL TION " / PUMP REPAIR-L-7 ; PUMP REPLACEMENT ;%f <br /> Other <br /> 'DISTANCE TO NEAREST: SEPTIC TANK At SEWER LINES PIT PRIVY <br /> SEWAGE-,DISPOSAL FIELD CESSPOOL/SEEPAGEPIT . OTHER J <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC -DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 10 <br /> Industrial .. Cable Tool Dia. Yof' Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public :Driven Gauge of Casing <br /> .Irrigation Gravel Pack r Depth of Grout,. - - <br /> eal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Iuformation . <br /> Geophysical Surface Seal 'Tnstal3ed B' i S <br /> PUMP INSTALLATION: Contractor 04PA11__- - 1. <br /> r <br /> _Type .of .Pump ..: H.P. <br /> PUMP REPLACEMENT: . / / State Work Done' <br /> PUMP .REPAIR: /_/ State Work Done <br /> I RE&TRUCTION.OF WELL: Well .Diameter Approximate Depth own <br /> Describe Material, and Procedure � <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> F and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> f 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 GROUTING AND A INAL INSPECTION. <br /> - SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE, <br /> ADDITIONAL COMMENTS: .417i <br /> PHASE II 9ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY �.-' �P; — DATE <br /> E0141'6"' 4/75 2M <br /> ,, <br />