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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t 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 &_-S 7r <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 AI a-A_/3 �_ t__ . % fCE TRACT <br /> Owner's Name Phone���'^`/��7 <br /> Address 10, ( 1 ?"C [n - City - <br /> Contractor's Name � - P. „ License I//.13 ? Phone - .3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR g• PUMP REPLACEMENT <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 "E. Drilled - r Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack I . Depth of Grout Seal <br /> Cathodic Protection Rotary i ,.Type of Grout _ <br /> Disposal Other, It Other Information <br /> Geophysical " ' Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump '' H.P. <br /> PUMP REPLACEMENT: / / State WorkDone-x <br /> PUMP REPAIR: ;State Work Done joA p C �- <br /> i <br /> DESTRUCTION 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 anew 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 kpowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUT AN)D A FI A NSPECTI <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) oOF <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> . APPLICATION ACCEPTED BY en, DATE S- J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 'INSPECTI PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE j22 <br /> F <br /> E H 1426 Rev. � l-74 6/%.7 _ 2M <br />#. - , <br />