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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR, OFFICE USE': 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2-Ss, JQ <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 is application made in compliance with San Joaquin <br /> County Ordinance No. 1862 he R nd egulSatian o (e San Joaquin Local Health District. <br /> JOB ADDRESS/LO CENSUS TRACT <br /> Owner's Name Y`-' Pho e�erA / l L/ <br /> Address C <br /> Contractor's Nam Licensm:)----�32�?Pho&w <br /> i <br /> TYPE OF WORK (Check) : NEW. WELL /—T DEEPEN /_/ RECONDITION -DESTRUCTION DESTRUCTION /-7AL <br /> PUMP INSTLATION REPAIR / PUMP REPLACEMENT /-7 <br /> Other <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 Cable Tool Dia. of Well Excavation (Z <br /> Domestic/private Drilled Dia. of Well Casing t`T <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: } <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> r <br /> PUMP REPAIR: State Work D °- - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby 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 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 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 GRO TING AND A FINAL INSPECTION. <br /> SIGNED TITLE _ <br /> DRAW TOT PLAN ON RE VEPSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE — <br /> ADDITIONAL COMMENTS; <br /> PHASE II SPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426379 <br /> Rev. 1-74 ' <br />