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SAN JOAQUIN LOCAL HEALTH. DISTRICT 9 <br /> E( F OFFICE USE: <br /> r 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z=640-d-&) <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 6-$7 <br />} (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District .for a permit to construct I <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ; <br /> County Ordinance No. 1862 and the*Rulesand,Re.gulations of. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONAIXI alo CENSUS TRACT <br /> kOwner's Name f^ Phone <br /> Address <br /> City <br /> Contractor's Name License ILZE2ZI Phone y <br /> � t <br /> TYPE OF WORK .(Check) : • i DEEPEN / / �'.RECONDITION LV DESTRUCTION /7 <br /> PUMP INSTAL TION / / -PUMP}REPAIR'/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES1 PIT�PRIVY -,,'',_ <br /> -SEWAGE�DISPOSAL' FIELD'-- -'-- --CESSPOOL/SEEPAGE PIT Y "'OTHER <br /> PROPERTY I,IT ;- PRIVATE DQMESTIC- WELL PUBLIC-DOMESTIC-WELL <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing � <br /> Domestic/public Driven Gauge of Casing k& IAl <br /> X Irrigation Gravel Pack 4Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> r R <br /> Geophysical Surface Seal Installed By: - y <br /> PUMP INSTALLATION; —'_ - <br /> ConCractor <br /> Type .of Pump H:P. <br /> PUMP REPLACEMENT:`' State Work Done <br /> PU AIR: State W <br /> / /, ork Donee - _ <br /> DESTRUCTION OF WELL: WellFDiameter Approximate Depth <br /> Describe Material and-„P'r.ocedifi7.,e <br /> i <br /> I hereby agree to comply with all lavas 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 f <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in; use. The above <br /> information is true to the be of knowledge and belief. I WILL CALL FOR A,IGROUT INSPECTION <br /> PRIOR TO UTING D A F A N N. - { <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) U ; <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> . <br /> APPLICATION ACCEPTED BY is DATE �(�- '-%J <br /> ADDITIONAL COMMENTS: , <br /> PHASE II GROUT INSPECTION PHAAE III/FINAL INSPECTIONr <br /> INSPECTION -BY­ _DATE _ ., .-INSPECTION BY .:- - - . DATE <br /> E H 1426 Rau- 1-7A if77- ;2M. <br />