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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FOArOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUC-TION OR PUMP PERMIT Permit No. --8;9 <br /> x�. THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued 7/9 79 <br /> (Complete In Triplicate) <br /> Application,eis 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 36� AlCENSUS TRACT <br /> Owner Q s Name AA A JAPhone <br /> 1�3�` Address City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/? DEEPEN '/ RECONDITION /-7 DESTRUCTION <br /> ! PUMP INSTALLATION /—/ PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> M SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ilPUBLICDOMESTIC 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 /> f Disposal Other _.._.�- Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP <br /> REPLACEMENT: State Work Done <br /> PUMP :REPAIR: f' State Work Done <br /> E&TRUCTION OF WELL: 'We'll 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 best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO ROUTING AN A FINAL INSPECTION. <br /> r SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 9m <br />