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A �I SAN—JOAWIN LOCAL HEALTH DISTRICT <br /> FOF�rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. P '(209) 466-6781 <br /> :APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1A 7 <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 work herein described. This application is made in'cbmpliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Re lations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION !. �U/� -- ,,° .4 L. CENSUS TRACT <br /> Owner's Name Phone <br /> 491 <br /> Address 30- 1 rnp City 1d?,4A11..-0(3 <br />+ Contractor's Name � 6 License 7Phone <br /> y_ w <br /> TYPE OF WORK (Check): `��NEW WELL / DEEPEN / / RECONDITION /-7. `DESTRUCTYON /-7 <br /> +PUMP'INSTALLATION /4 PUMP REPAIR / I PUMP REPLACEMENT /7 <br /> ' then / J -- <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 �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial moble Tool I Dia. of Well Excavation f/ <br /> 4--Bomestic/private , `` <br /> ) Drilled Dia. of Well Casing �. <br /> Domestic/public # Driven Gauge of� Casing <br /> Irrigation Gravel,Pack Depth of Grout Seal � <br /> • .rte,. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information. <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done - <br /> ` <br /> ES:!RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby 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 completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of-lithe well and notify them before puttingthe..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 GROWING. AND A F'I INSPECTION. <br /> SIGNED TITLE , <br /> n� (DRAW PLOT PLAN ON REVERSE SIDE) _. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .. DATE <br /> II <br /> ADDITIONAL COMMENTS: - •. <br /> PHASE -II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY I�' DATE INSPECTION BY eerAV DATE J� <br /> t E H 1426 Rev. 1.-74 1-74 gM—�~ d <br />