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tig VSAN' JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF ;'OFFICE USE: 1601 E. Hazelton A_ve, -, ,Stockton, Calif. <br /> Telephone: +`209) 466-6781 <br /> k :FAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I� THIS PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED Date Issued <br /> b (Complete In Triplicate)g (Application is'hereby made to the San Joaquin Local kiealth District 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 /> li <br /> { JOB ADDRESS/LOCATION 6 0 r j XENSUS TRACT <br /> Owner's Name -- 'moi,,, ..r. .. . Phone ' J- . 0 <br /> Address •.g JB City <br /> Contractor's Name "' <br /> . License # . d � Phone infr ti.c2 2) <br /> a <br /> j!NEW WELL /. / DEEPENJX_/_ RECONDITION-/_7_ :DESTRUCTION�,/,j,. <br /> PE OF WORK (Check): i _ <br /> _ _ -. <br /> PUMP INSTALLATION / / UMP REPAIR - <br /> )? / PUMP 'REPLACEMENT /? <br /> Other <br /> H <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 /> INTENDER USE TYPE OF WELL CONSTRUCTION_SPECIFICATIONS <br /> Indus trial, Cable Took. „Dia. of Well Excavation � �. <br /> Domestic/Private;` Drilled Dia .eof Well Casing I �' /�, <br /> Domestic/public �! Driver: Gauge of :Casing �1 <br /> k Irriga-tion=.-----� �! Gravel Pack Depth of Grout Seal "•• <br /> Cathodic Protection - Rotary, _Type- o ..Groutr <br /> �- Disposal-­ ! a Other Information <br /> r Geo"physical.: - `Sur-f ace"Sca1,�sta1•Ied 'B <br /> ' z <br /> k PUMP INSTALLATION: ;;Contractor <br /> ,:Type of Pump <br /> PUMP REPLACEMENT: ,, ` -State Work'Done .� <br /> PUMP REPAIR: ,r,/ 41 <br /> / 'State Work Done; s` <br /> DES TRUCTION..:OF' :.ELL. _ ,We11 Approximate Depth <br /> ` k - <br /> :Describe Material and Procedure <br /> I hereby agree to complywith all laws and regulations of the San Joaquin Local Health District <br /> and the State of`California pertaining tcs gr regulating well"construction. Within (FIFTEEN DAYS <br /> after comp let on• pf y�;iork on a new well, I will furnish the San :Toaquin Local Health District a <br /> WELL DRILLERS REPORT:of-:-this-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 /> iPRIOR TO GROUTING AND AlF'INAL INSPECTION. v <br /> SIGNED TITLEr <br /> RA T PLAN ON REVERSE SIDE <br /> FOP, DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY / DATE <br /> ADDITIONAL COMMENTS: " " j <br /> PHASE II GAO SP CT "-`_­P1 SE III FINAL INSPECTION <br /> INSPECTION 'BY . AT3E INSPECTION BY.. DATE 1„_!3" <br /> 1 E H 1426 . Rev., 1-74 r' 3 /75 2M <br />