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�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICE USE: �; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z, -,;L4$p <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. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION 1 vi�o g �. J�u _1V ja CENSUS TRACT <br /> Owner's Name V4g f1 �1 1Q Phone Q�j� `'34? <br /> Address a Y*7 e, City a e-Ako <br /> Contractor's Name :.D.Aj 44..) License #,p2)96/0 Phone 2.2c1_7 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN ,/7 RECONDITION %T DESTRUCTION / j <br /> PUMP INSTALLATION /-7-pump REPAIR / PUMP REPLACEMENT 1 <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 /> �+ 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 BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . State Work Done <br /> PUMP :REPAIR: State Work Done <br /> DESiTRUCTION 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-beat of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NG AN A INAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SI <br /> FO <br /> PHASE I DEPARTMENTUSE ONLY <br /> APPLICATION ACCEPT= r LJ V�T DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION_ PHASE II AL' NSPECTI <br /> INSPECTION BY DATE INSPECTION BY E <br /> E H 1426 Ren. 1-74 h/75 2M <br />