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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;'OFFIC USE: /1601. E4 Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4664.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE `ISSUED Date Issued-&--z-_ <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 inscompliance with San Joaquin <br /> County Ordinance No. 1862 -and the Rules and Regulations df_ the San .Joaquin,Loca1 Health District. ' <br /> 30B ADDRESS/LOCATION /qo,/ w •_djp .. ,.:., ENSUS TRACT <br /> Owner's Name = r . . . ....: <br /> r Phone9. <br /> Address <br /> city. �' l /d.•� <br /> Contractor's Name � pp __A�,,�� �_ # n <br /> _��Yl._�.�` �� ..,•.___.,.,. ,_,•,.�, .. License # ti Phone <br /> a <br /> TYPE OF WORK (Cheek):-,1, <br /> NEW WELL /? DEEPEN /? RECONDITION./�•, DESTitUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR_'/-7 <br /> ALPUMP REPLACEMENT-. <br /> DISTANCE TO NEAREST: �SEPTIC' TANK SEWER LINES PIT PRIVY <br /> /SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER J <br /> ,,PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q , <br /> INTENDED USE TYPE OF WELL vv <br /> '. CONSTRUCTION SPECIFICATIONS � <br /> Industrial (Ni. Cable Tool— Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Px_otec,tion Rotary .,Type of;Grouti <br /> Disposal Other - Other Information <br /> Geophysical Surface S _aa1-Installed 'By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . ;; ,. .. . <br /> H.P. <br /> PUMP REPLACEMENT: # " 1„' . <br /> / / State Work Donees - 9, i <br /> • •• S. <br /> - <br /> F MP REPAIR: /7 State Work Done` <br /> DESTRUCTION OF WELL: Well Diameter-,0 4 Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with al-1-laws and regulations of the San Joaquin Local Health District <br /> and the State of .Califorriia, pertaining to or regulating well "construetion. 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 .o£ my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> IN <br /> FRiOR TO GRO INC ANDA IN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> T <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCENTED BY DATE -� <br /> ADDITIONAL COMMENTS:. <br /> PHASE II GROUT INSPECTION PHAS& III INAL INSPECT12 <br /> INSPECTION B$ DATE INSPECTION BY DATE. <br /> Rev. 1-74 rr y,/� mar <br />