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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> s'= <br /> POE.OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. !v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> t0 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 permit to construct <br /> and/or install the work herein described. This application is.made in compliance with San Jpaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Digtr�ct. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name AF Phone Y z <br /> i ` _ <br /> ..Address. - <br /> �- - - City 1/cs. <br /> Contractor's Name a' _ License.-!� Phone -S/ <br /> TYPE OF WORK (Check) : NEW WELLY DEEPEN '/—/ RECONDITION /_ , DESTRUCTION /-7V , <br /> PUMP INSTAL TION / / PUMP REPAIR /7 ; PUMP REPLACEMENT /7 <br /> Other '/ <br /> DISTANCE TO NEAREST: SEPTIC TANK,<O0 ;tSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELT ,- PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing &j <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack ,Depth of_ Grout Seal` <br /> 6 Cathodic Protection Rotary Type of Gr6u t — <br /> Disposal' 1 Other Other Information „ <br /> Geophysical Surface Seal Installed By: S <br />. PUMP INSTALLATION: Contractor — <br /> Type of Pump H.P. , D <br /> PUMP REPLACEMENT: / / State Work 'Done <br /> PUMP '.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe Material and Procedure S <br /> I iierreby agree to comply with' all laws 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 <br /> .completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the W' a notif them before putting the well in use-. The above <br /> information is true t the b t o <br /> aa-Ad- <br /> edge and belief. I WILL CALL FOR A GROUT INSPECTION r <br /> PRIOR T I GAN FIN ' N ECT t <br /> SIGNED TITLE A <br /> s ( W-PLOT PLAN -ON--REVERSE-SIDE) F <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 'I <br /> APPLICATION ACCEPTED BY DATE `/ -2/ , <br /> ADDITIONAL COMMENTS: ! <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> E H 142A Ru,. _7 1X77 : ?M <br />