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R <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � f <br /> Telephone : (209) 466-6781 <br /> F <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. IZO <br /> f <br /> `i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> k V"� ' (Complete In Triplicate) <br /> Application is hereby de 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 Jo$quin <br /> County Ordinance No. 1862 aTd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION •�- �� �' CENSUS TRACT <br /> f Owner's Name 6 /C as Phone � � <br /> i AddressC �� <br /> -'sCity 9-k-22 - <br /> Contractor'sk <br /> Name 413 o <br /> License Phoneu 91 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION M PUMP REPAIR j / PUMP REPLACEMENT /_ <br /> Other. / f <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <br /> k 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 /> Industrials---- - a Cable_Tool Dia. of Well Excavation <br /> ' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge{of Casing v <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> .Cathodic Protection I Rotary Type of Grout <br /> t <br /> ..—Disposal I Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Typf Pump H.P. <br /> PU"NP REPLACEMENT: <br /> / / State Work Done <br /> PUMP .REPAIR: % / State Work-'Done <br /> PES-TRUCTION OF WELL: We 11 -Diameter 4i.: Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of .the San Joaquin Dotal 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROPTINC ANDA AINAL. INSPECTION. <br /> SIGNED TITLE ( ¢' <br /> iDRAW T.LQT PLAN ON REVERSE SIDE) 4j <br /> FO DEPARTMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEPTED BY !� DATE <br /> :ADDITIONAL COMMENTS: <br /> PHASE II ROU S CTI P S I/FI AL INSPECTION <br /> ;INSPECTION BYE ( INSPECTION B DATE <br /> E.. 1177 2M <br /> H 1426^ Rev. 1-74 <br />