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�_. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOArflFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> F <br /> APPLICATION FOR WELL CONSTRUCTION OR .PUMP PERMIT Permit No. _-,1_0310 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2=.1-41-7-1- <br /> Application i 1 (Complete In Triplicate) <br /> App s hereby made <br /> y to the San Joaquin focal fIealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> 'County Ordinance No. 1862 and the RulesPT and- Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 / ZWO s �: CENSUS TRACT !3 22z -vJ <br /> Owner's Name r <br /> Phone �G <br /> Address Q City '' <br /> Contractor's Name <br /> License IY6 7-3 Phone3 <br /> C <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/? RECONDITION /_7 DESTRUCTION f7 <br /> PUMP .INSTALLATION / ./ PUMP REPAIR ,PC/��PUMP REPLACEMENT 1-7 <br /> Other: / / — <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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well -Excavation <br /> a � <br /> Domestic/private # DrilledDia. of Well Casing t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation "r - -Gravel Pack Depth of Grout Sealj <br /> Cathodic Protection 1 Rotary !Type of Grout ; <br /> :Disposal--,}� a- -� �, Other Other Information <br /> ... .._ _ Surface Seal Installed B <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump ' <br /> PUMP REPLACEMENT: State Work Done <br /> 'f <br /> �•� <br /> .REPAIR: State Work Done` ° IL <br /> `+ <br /> ES�TRUCTION OF WELL: Well Diameter Approximate epth <br /> Describe Material and.-Procedure <br /> ! i <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—the—well in-use.. The above <br /> information is rue to the best-of- my.knvwledee and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO G AND A F I INSPECTI.ON. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I a <br /> APPLICATION ACCEPTED BY �= <br /> 2DATE ; <br /> ADDITIONAL COMMENTS: _44 s <br /> PHASE II GROUT INSPECTION <br /> ' PHASE IX IFI INSPECTION/ J.� <br /> INSPECTION BY DATE INSPECTION BYC21 DATE 311 d <br />. E <br /> `1 yE H 1426 Rev. 1-74 1_74 lu <br />