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v,rn,k�r�o SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> /111� <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3 <br /> -J` (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 Jos. uin Local Health District. <br /> JOB ADDRESS/LOCATION Sok „ ;r e <br /> �� �`' � � �,` :�'(CENSUS TRACT <br /> Owner's Name Ag.'a��6��rc ,� I'" .f Phone <br /> Address I U �'. r-�.s x c <br /> '� �� City4"rrorre,< <br /> Contractor's Name 'r License # / 7 .!"Phone ? : <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR / / PUMPPLACEMENT �J <br /> 0 her J , <br /> S m,w/ A."&,11 4 A toy 7° 95 ,w,,t / <br /> DISTANCE TO NEAREST: SEPTIC TANK ISEWR 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 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 7 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. <br /> WO <br /> PUMP INSTALLATION: Contractor �+ 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP REPAIR: /_7 State Work Done <br /> PES TRUCTION 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 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._Qf my knled' and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG UTING AND A FINAL t N <br /> SIGNE ITLE_11j-� <br /> DRAW PLOT PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r7 <br /> ti E H 1426 Rev. 1-74 1-74 2M <br />