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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo-K OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9,f­_-�06 <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED - Date Lssue#ja a- W <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 compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. F, CENSUS TRACT <br /> Owner's Name Phone <br /> Address Ar Citylow _ <br /> Contractor's Name License � iF�Pha <br /> i <br /> i <br /> I <br /> TYPE OF WORK (Check) : NEW WELL _ DEEPEN / / RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / % PUMP REPLACEMENT /� f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY w <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> dustrial ° Cable Tool Dia, of Well Excavation <br /> omestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven, _.Z -Gauge of Casing <br /> Irrigation '.� J V. CA V Gravel"Pack - Depth of Grout Seal <br /> Cathodic ary—i Type of'Grout � �- <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal Installed By:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor' <br /> ".Type of Pump - * ,r H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done r .� <br /> PUMP .REPAIR: / / State Work-Done _ .. <br /> DESTRUCTION OF WELL: Well Diameter r 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 the well and notify them before putting thewell 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 GUFLAND A FINAL INSP CT <br /> SIGNED TITLE ° <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE INAL INSPECTIOU <br /> INSPECTION BY DATE _ INSPECTION BY DATE _ <br /> t <br /> ^ 0!77 <br /> E H 1426 Rev. . 1--71, 2M <br />