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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR-OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> 7 7 ,, Telephone: (209) 466-6781 <br /> r r�E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued m6 7 1 <br /> ' � <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein de ibed. This application is made in compliance with San Joaquin <br /> Cou4ty Ordinance No. 1862 and the Rules anulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION_ IL <br /> - CENSUS TRACT <br /> �0& 6 il,/ej tt(( <br /> Owner's Name Phofie5� <br /> Address City <br /> Contractor's Name License # e3Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN %/ RECONDITION /-7 DESTRUCTION /-] <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK > SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD _,62Qf CESSPOOL/SEEPAGE PIT OTHER CC)Rt--AVIO 6 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL now <br /> INTENDED USE TYPE OF WELL �- CONSTRUCTION SPECIFICATIONS (1� <br /> Industrial Cable Tool Dia. of Well Excavation '> _. <br /> X _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection >_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />, DES•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 thewellin 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-p6UTING ANDA INAL INSPECTION. <br /> SIGNE TITLE <br /> W� PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY (0 6 ? � �+LsrAj <br /> PHASE I Hwy <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 1ZLfFINAIWINSPEMON <br /> INSPECTION BY DATE INSPECTION BY 46ZL4gLA4t4tDATE <br /> E H 1426 R(e). 1-74 BsexNf, & G✓,v Com! <br />