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_ cd SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOErOFFICE USE: ' I1 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �- S <br /> THIS-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �a7� <br /> (Complete In Triplicate) <br /> Application is hereby ssnade 'to the San Joaquin Local Health District for a permit to construct <br /> and/or install theworkrherein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18b2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION ' - <br /> Owner's Name *� �✓ rZen <br /> Phone <br /> P <br /> Address" City 1� <br /> ' ^ z <br /> . ��l3� Phone 3 c S <br /> License.-#/ <br /> Contractors Name -----� - <br /> TYPE .(Check): NEW-WELL -j�=-RECONDITION /-7 --DESTRUCTION rT <br /> PUMP{INSTALLATION / / PUMP REPAIR g PUMP REPLACEMENT /_7 <br /> Other / / <br /> I� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 9 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation <br /> f Domestic/private Drilled Dia. 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 Information _ <br /> Geophysical �� Surface Seal Installed B <br /> PUMP INSTALLATIONS [ Contractor '� .A, 0' ' Y <br /> Type of Pump '' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: State Work Done' - <br /> 4ES;TRUCTION 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 /> f and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion ofury 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 FORA GROUT INSPECTION <br /> PRIOR TO GE3UI4P AND "k NAL INSPECTION. <br /> SIGNED TITLE �� <br /> �M RAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY ! <br /> ADDITIONAL COMMENTS: <br /> PHASE IIRGROUT INSPECTION PHA II ,FINAL INSPECTION <br /> INSPECTION BY iM DATE INSPECTION- BY DATE ^�G_ �y <br /> :E H 11+26 Rev. 1,'74 1-74-2M <br />