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� 4 <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT / 'A <br /> FOP OFFICE USE: 1601 E.- Hazelton Ave. , Stockton, Calif. , <br /> -. �-. 0 g Telephone: (209) + 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 Health District. ! <br /> JOB ADDRESS/LOCATION r <br /> CENSUS TRACT <br /> Owner's Name 19A4 Phone es? 2.1 <br /> AddressvA. <br /> CityC <br /> Contractor's Name r License Phone --t I <br /> t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ /-7/ RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTAL ATION / / PUMP REPAIR 17 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /YQ ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL r <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q � , <br /> Industrial T-.-- � _ T Cable Tool Dia, of Well Excavation ff - �? 'yam <br /> ` Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> \ '.IrrigationGravel Pack Depth of Grout Seal <br /> Cathodic _Protection Rotary Type of Grout <br /> Disposal Other w Other Information <br /> Geophysical Surface Seal}.Installed 'B : <br />= .UMP INSTALLATION; Contractor <br /> r ` . Type of Pump H.P. <br /> PUMP REPLACEMENT: , /�/ State Work Done <br /> PUMP -.REPAIR: State Work Done 01 T' <br /> DESTRUCTION OF WELL: We11 Diameter[/.VUc�P`/ z e:A" GyP pproximate Depth �� , <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distriqt <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 n tify them before putting the -well in use. The above <br /> information is true to th be a my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T OU ING D A F N ION. <br /> SIGNED TITLE <br /> (DRAW'PLOT PLAN ON REVERSE SIDE) <br /> --�— - -FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE v <br /> ADDITIONAL COMMENTS: <br /> P E G OUT IN PECTT N PHASE IJFINPA INSPEC <br /> INSPECTION BY , DATE INSPECTION BY AT <br /> 1 177 2M <br />