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60%p J6/,�4w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE, 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d d <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and .Regulations of the San Joaquin Local' Health District. <br /> JOB-ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Names �j�..�a Phone <br /> Address _q '74 © e—'r Q�Q tae -� City �Fr4;sl <br /> Contractor's Name License #�,�Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN RECONDITION RECONDITION / / DESTRUCTION /_7 _ <br /> PUMP INSTALLATION / PUMP REPAIR f / PUMP REPLACEMENT <br /> Other /_7 O <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 <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 ; f State Work Done Xa) A)P11 <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 /> m kno 1e e and belief. I WILL CALL FOR A GROUT INSPECTION <br /> information is true to the best 4— <br /> PRIOR TO GROU ING AND A FINAL I CTI N <br /> SIGNED TITLEj ' . <br /> - -- <br /> (D!LAW PLOT PLAN ON MVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY //� '.� - DATE 3 /d ` 7,F <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION MSE_ I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B a,4 DATE } -#(-70- <br /> E H 1426 Rey. . 1-74 <br /> 017.7 2M- <br />