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SAN JOAQUIN LOCAL HEALTH DISTRICTa f? <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. U-t2 ({/! <br /> Telephone : (209) 466-6781 �� r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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. This application is made in compliance with San JoeQuin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 177610FT VQ <br /> CENSUS TRACT <br /> Owner's Name PJ9 JzA atS _C10SOAl Phone z- 1126 7� <br /> Address <br /> Contractor's Name . =Q ? Q License # 716a2 Phone `�L26-s17 <br /> s <br /> TYPE, OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP 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 / <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S <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 /> PUMP -.REPAIR: / / State Work Done <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE1�C_.. <br /> (DRAW PLOT LAN ON REVERSE SIDE) j <br /> FOR EPARTMENT USE ONLY <br /> PHASE I /` <br /> APPLICATION ACCEPTED _ c/. DATE f 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 I / � �r/S � �17.7 _ . 2M <br /> Rev. 1-74 `� 7 <br />