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91. SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOE OFFICE USE: // 601 E. Hazelton Ave. , Stockton, Calif. <br /> v Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, _ <br /> i J <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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. cc1��862and the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION.✓,/ �� k Aq- � � a/, NSUS TRACT <br /> Owner's Name � Phone f3 T <br /> Address _ City ' <br /> Contractor's Name 60 License #/62371 Phoney6:C k <br /> TYPE OF WORK (Check): NEW WELL 6/—/- ,DEEPEN / / RECONDITION /_7 DESTRUCTION /_]" <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> other-'I <br /> DISTANCE TO''NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 /> Industrial `'" 1s Cable Tool Dia. of Well Excavation <br /> Domestic/private It, Drilled Dia. of Well Casing <br /> Domestic/public ! Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal F Other Other Information <br /> '4- ,Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ �{ <br /> Type of. Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done .� <br /> PUMP -REPAIR: -� State Work`Done GA p <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure. <br /> I hereby agree to comply with,411 lams and regulations of the San Joaquin Local Health District' <br /> and the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS j <br /> after completion of my work on a new well, I will furnish the Sart 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 mkn <br /> y o ledge and belief. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GRO G D A ALINSPECT <br /> SIGNED UTITLE <br /> ,.. t-,-- . . D 4 PLAN ON REVERSE SIDE .1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL �CflMMLNTS. <br /> ' - i} °� <br /> PHASE''II 'GROUT 'II19SPECTION PHAS I I/FI INSPECT- <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 014 <br /> E H 1426 Rev. 1-74 i 3/76 29, $ <br />