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`/wl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFI OFFICE USE: '�. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6 /S"u1 <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 /> Jos ADDRESS/LOCATION �Cfil' ' - I CENSUS TRACT <br /> Owner's Name PLWTISNe <br /> Phone <br /> Address L <br /> City 1 <br /> Contractor's Name LE 4 <br /> License # ( Phone <br /> y <br /> TYPE OF WORK (Check): NEW WELL. / DEEPEN /_7 RECONDITION / DESTRUCTION /7 <br /> PUMP INST LATION _7 PUMP REPAIR /� PUMP REPLACEMENT /-' <br /> OtherLY <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r( <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of We11 Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing '�� <br /> Domestic/public Driven Gauge of Casing /Z <br /> Irrigation a . <br /> Gravel Pack Depth of Grout Seal � l" <br /> Cathodic Protection _Rotary Type of Grout <br /> Disposal __ Other El r. <br /> Geophysical Other Information <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> A.P. <br /> REPLACEMENT State Work Done <br />_12a, /_7 State Work Done \ <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 put ting_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 /> SIGNED _ " <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> ' <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE\ I FOR DEPARTMENT USE ONLY <br /> APPLI TION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE - > 'y INION BY <br /> 1 - DATE 9 <br /> SPECT _ ,F <br /> '426 Rev. 1-74 1./7K <br />