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� t <br /> { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 'CA", <br /> �` >� <br /> FOR_ OF-U- 12 USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 1f/4 <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 /> AV <br /> JOB ADDRESS/LOCATION { r 0 F l41 ..5 .�C NSUS TRACT ' <br /> Owner's Name p Phone 36f '� f \' <br /> U I <br /> Address s <br /> #w-Acity <br /> SContractor's Name &0 �4 //� License # I7;)9/'Phone <br /> iIle <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / ./AL _RECONDITION /� DESTRUCTION <br /> PUMP INSTLATION / / PUMP, REPAIR J / PUMP REPLACEMEN /_7 <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 /> i 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 tea . Type of Grout it <br /> Disposal Other Other fYnformation,= - ! <br /> Geophysical Surface Seal Installed By: <br /> ' f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.. <br /> PUMP REPLACEMENT: / / State Work Done <br /> W <br /> PUMP -.REPAIR: / J State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate{Depth o� <br /> Describe Materia and Procedure -r#ez d <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 orregulating we11"constru6tion._. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish, the San Joaquin Local Health District <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 /> PRIOR TO 5§2UTIA AND A FINAL INSPECTION. <br /> SIGNED TITLE I . � <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE TI/FINAL INSPECTION <br /> ,INSPECTION BY DATE INSPECTION BY DATE 1 ., ' <br /> R H IL26 Reair. i_7L. / .. 1177--_ 2M <br />