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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFOF OFFICE USE: _ 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /4r <br /> r <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 Heal.th,Dlstrict. <br /> k JOB ADDRESS/LOCATION `'ld pyc.) O ENSUS TRACT `Z25— O -Za <br /> Owner's NameA2e Phone <br /> Address ®_ <br /> city <br /> Contractor's Name 1 04 �Q License # 14phone <br /> TYPE OF WORK (Check) : NEW WELL / ,/ DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PINlP_,REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: cSEPTICITANK _SEWER`LINES PIT PRIVY <br /> SEWAGE %DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT - OTHER <br /> PROPERTY LINE.-_-*PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE .OF WELL I- - 4. .r ' : CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private f. Drilled Dia, of Well Casing <br /> 4 Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection. : _. Rotary Type of Crout <br /> Disposal I Other , Other Information . <br /> Geophysical Surface <br /> �., .s� Seal Installed By. Q <br /> F PUMP I <br /> NSTALLATION '^ Contractbr <br /> .' Type _of Putup4% -. H.P. . <br /> PUMP REPLACEMENT: <br /> State Work Done PUZZW I&RI-Q11 GC.1 <br /> f <br /> PUMP REPAIR: / / State Work Done <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 "coristruction. , '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 FOR A GROUT INSPECTION <br /> PRIOR TO G^UTING AND A-FI AL INZPECTION. <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY DATE <br /> 11> <br /> ADDITIONAL COMMENTS: - <br /> PHASE II G INSPECTION PHASE I /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE/G / <br /> 1 ,7 <br /> p j <br />