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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE -USE: 1601 E. Hazelton'Ave. , Stockton, Calif. <br /> Telephone:p {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�!8`-y7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct,,,-,% I <br /> and/or install the work herein described. This application is made in compliance with San Joaquin_ <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health.District <br /> JOB ADDRESS/LOCATIq <br /> CENSUS TRACT *i <br /> Owner's Name <br /> / Phone <br /> Address <br /> city �1&x .. <br /> Contract ' Name ' License #,;V46 o Phone <br /> TYPE OF WORK (Check) : NEW' WELL /-7 DEEPEN /__7 RECONDITION DESTRUCTION r7 <br /> PUMP INSTALLATION / / PUMP REPAIR, /"/ PUMP REPL,ACEM$NT / <br /> Other J-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTICWELL— <br /> INTENDED Y; <br /> USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial <br /> Cable Tool Dia, of )Well. Excavation <br /> Domestic/private Drilled pia, of 'Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Iriformation <br /> Geophysical Surface .Seal Installed B <br /> -PUMP INSTALLATION: Contractor � G� �;;.`t;:• <br /> Type of Pump <br /> R.P. <br /> PUMP REPLACEM$NT: / / State Work Done �G�c `t A <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION `OF WELL: Well Diameter`s Approximate Depth A . :. <br /> Describe Materiali.and Procedure-- \f <br /> I .'herebY agree s to c h` <br /> g comply with all laws and regulations of the Joaquin Local Health Dfetrjct <br /> and the State- of California pertaining to or regulating well construction. Within FIFT W IY[T$ <br /> after completion of my work on a new well, I will furnish ihe,San Joaquin Local Health District a <br /> WELL' DRILLERS REPORT of the well and notify them before putting the- well in use. The ab6ve <br /> information is true Ca •the-b�st•of myknowledge and belief; Z WILL CALL F A GROUT_�RSPL+CTI2N, <br /> PRIOR TO'.G UTINGr:AN - ' FINAL-INSPECT—ION,,—.. <br /> SIGNED s TITLE <br /> W' PLAN <br /> 'ON SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> .t. <br /> APPLICATION ACCEPTED BY DAT$ — -`.;77 " <br /> ADDITIONAL DOM M$NTS: <br /> PHASIC II (Off 5SPBCTION 1 PILOSE FINAV INSPECTION'' <br /> INSPECTION BY DATE INSPECTION BY 61./ _ DATE <br /> E B 1426 Rev: -I-74 <br />