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_# SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I� FOR OFFICE USE: 1601 E. Hazelton,. Ave. , Stockton, Calif. <br /> Telephone : -, (209) 466-6781 <br /> APPLICA'T'ION FOR WELL CD�STRUCTION OR PUMP PERMIT Permit No./ <br /> THISxPERMITIEXPIRES I 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 incompliance with San .Joaquin <br /> County Ordinance No. ,1862 .and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/ 6�£d. Ala Gly/7 CENSUS TRACT -- <br /> Owner's Name` 4 pfe'��' _ Phone <br /> Address --. - „ J. ,. <br /> City <br /> Contractor's Name ��1��!'°`�P.� �"!f�' �f' License Y j�?G�Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /�/ DERTRUC'TION /^_T <br /> PUMP °INSTATION I PUMP REPAIR / / FUMP REPLACEMENT I <br /> Other! / / --- <br /> DISTANCE TO NEAREST: SEPTIC, TANK Q S <br /> SEWER LINE -- PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r' <br /> PROPERTY LINESS PRIVATE DOMESTIC WELI,419!t PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation _4 <br /> Domestic/private 11 - Drilled Dia.; of Well Casing , <br /> i <br /> Domestic/public I Driven Gauge of Casing [U � <br /> Irrigation t_ Gravel Pack Depth of Grout Seal ',_ 769 ea--_ <br /> Cathodic Protection Rotary Type of Grout E ' <br /> Disposal Other Other Information <br /> Geophysical. Surface Seal. Installed By: <br /> PUMP INSTALLATION: AIA4 <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> T i <br /> 4DES-TRUCTION OF WELL; Well Diameter y Y` Approximate Depth <br /> Describe Material and Procedure "F~ <br /> I hereby agree to comply with all laws and regulatioiis 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 <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 GROUTING AND A FINAL INSPECTIO <br /> f SIGNED --TITLE <br /> PL P ON REVERSE SIDE) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z2 7� <br /> ADDITIONAL COMMENTS: { <br /> I GROUT INSPE ON P / NAL INSPECTIO <br /> f INSPECTION BY ! DATE INSPECTION BY DATE <br /> 2M <br /> P R 1496 Rav_ . 1-74 <br />