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__ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: OL,/ 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, r S6 <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 workliherein. 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 /> r <br /> JOB ADDRESS/LOCATION.-P ,. CENSUS TRACT <br /> Owner's Name I Q,�iV Phone <br /> �! <br /> Address City ,Gam ' ,✓ 4 <br /> �F L <br /> Contractor's Name 9--a" ,L/ JQd Ij License ��,2 /� Phone__ f �7 <br /> I <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ <br /> AL _ <br /> *RP'-INSTLATION � PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY G J <br /> SAP <br /> EWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 7 OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL _ p <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 i� Driven Gauge of Casing G <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By-: - <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: k State;Work Done f <br /> PUMP .REPAIR: �.+ /, /; ,State Work Done �'l } <br /> DESTRUCTION OF WELL: Well Dameter t pproximate Depth <br /> Describe Material and'Prodedure <br /> I hereby agree to comply`: with all-laws and regulations of thd- San .Joaquin Local Health District <br /> and the 'State 'of California pertaining to cr regulating well'c.onstruction. . 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 j,�the well and notify them before putting thewell 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 GROUKNG AND A 'F` I3,i IN PECTION. i <br /> SIGNED h <br /> TITLE <br /> �M (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ' ' /L�.rY DATE 1,2 <br /> ADDITIONAL COMMENTS: <br /> PHASE..II GROUT"INSPECTION PjjkSEppaI_i1i ITSPECTION A <br /> INSPECTION BY DATE INSPECTION BY4Z <br /> E H 1426Rev. • 1-74t., ,�7 2M <br />