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took ,0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> !OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. % <br /> Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin <br /> County Ordinance No. 186'2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> i` <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> 22212 <br /> Owner's Name ca Phone t <br /> Address � � eQ_ ' �'P�^M2 ,n ,. City <br /> Contractor's Namecl License #/tjZj.s Phone AG , W 7e <br /> r:. <br /> TYPE OF WORK (Check): NEW WELL -/7 DEEPEN -/7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other f-7 4 <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 /> 4 Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing N <br /> --: Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout . <br /> Disposal !' ' Other Other Information <br /> Geophysical V Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> n <br /> PUMP REPLACEMENT: H State Work Done <br /> PUMP `.REPAIR: 7 State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth <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 I <br /> WELL DRILLERS REPORT of 'the well and notify them-before putting-the- well in-use.. The shove <br /> information is true to the"best ofkn edge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO G,ROUZING AND A FINAL INSP CT N <br /> SIGNED _ AITLE <br /> P T PLAN ON ;5�RSE SIDE <br /> FOR .)EPARTMENT USE ONLY <br /> PHASE I ;. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br />.1 E H 1426 Rev. 1-74' 1-74 2M <br />