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II� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSOFFICE USE: G 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedd�-?S <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 Salt Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION;'�l�` � r� ��r CENSUS TRACT <br /> Owner's Name Z2 2 � Phone 9,^ -7 f, <br /> Address ` City Z 11 <br /> Contractor's Name ?i3 G License �Phone "d� . ' <br /> TYPE OF WORK (Check): NEW WELL 0 DEEPEN/7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION L,7 PUMP REPAIR L-7 PUMP REPLACEMENT L7 <br /> Other /� 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 NEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation . i <br /> ,Y,', 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 Grout1- <br /> Disposal Other Other Information <br /> _Geophysical Surface Seal Installed By: <br /> PLW INSTALLATIONS Contractor <br /> Type of Pump ,c: .P. _,,__ <br /> PUMP REPLACEiCMs L7 State Work Done <br /> PUMP :REPAIR: L7 State Work Done <br /> P&S`Ru`ON 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 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 FOR A GROUT INSPECTION <br /> RIOR TO gROUTING AN A FIZ&AL INSPECTION. <br /> SIGNED Ari TITLE � �'� '� <br /> IryA <br /> W PLOT P ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE —3.5 - 5 _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II I P ION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _ <br /> `; E B 1426 Rev. 1-74 1-74 ZK <br />