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tSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORi'OFFICE USE: 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 Issued /o�7;16 <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 ,� 9� �Gi tr <br /> CENSUS TRACT <br /> Owner Q s Name Phone ai 3 _ 3 7 Yd <br /> Address 2 <br /> City <br /> Contractors Name - License # ZZb1,2 Phone YZ,7-Y,5 7 <br /> TYPE OF, WORK-(Check): NEW WELL DEEPEN /_7 RECONDITION /-7 DESTRUCTION /-7 <br /> E � PUMP INSTALLATION /% PUMP REPAIR /% PUMP REPLACEMENT /7 <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> s SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> .P-ROPERTY-LINE---PRIVATE,MMES TIC `PUBLIC -DOMESTIC WELL <br /> INTENDED USE 1 TYPE OF WELL CONSTRUCTION=SPECIFICATIONS , \ <br /> Industrial X Cable Toolo.� Dia. of Well Excavation J� <br /> Domestic/private Drilled Dia. o€''Well Casing <br /> Domestic/public Driven Gauge of, -Casing ,Mir <br /> E <br /> Irrigation , Gravel Pack .Depth of Grout Seal <br /> Cathodic Pro - <br /> Protection Rotary -Type,of Grout <br /> Disposal Otherfi'Other Information <br /> Geophysical Suface Seal Installed BY: <br /> 5 t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump. H.P. <br /> i <br /> PUMP REPLACEMENT: /1"/'+° 'State° Work Done <br /> P :REPAIR: / State Work Done <br /> ,UES�bUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material -And Procedure y <br /> I "trereby agree to comply with all laws and regulations of the Sanj�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 .wi.11._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 tru to the-best of my.knowledge and belief. I WILL CALL FOR A GROUT- INSPECTION <br /> PRIOR TO GROUTI AND AL SPECTION. <br /> SIGNED TITLE .L <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: ` E <br /> PHASE II GROUT INSPE7YON PHASE II FINAL INSPE O <br /> INSPECTION BY DATE® INSPECTION BY Ll DATE i <br /> E H 1426 Rev. i-74 �c ��V _ 1-74 2M- <br />