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SAN J'OAQ6� 4LOC,ALHEALTH DISTRICT. <br /> F0$ OFT CE USE: if 1601 E. Hazel.�on Ave.., -,Stockton, Calif. <br /> Telepbdfie : (209,) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED Date Issued a2 <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: Kules and Regulations of the San- Joaquin Local Health--District. <br /> JOB ADDRESS/LOCATION / . 7 `� --A_'14, CENSUS TRACT <br /> Owner's Name �„ 0 Phone - <br /> T j <br /> Address A � s 1-7 City <br /> Contractor's Name License #IJ -7 IPhone <br />;"TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION C/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <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 ! s Driven Gauge of Casing <br /> Irrigation i 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 ,r <br /> Type of Pump <br /> f _ <br />( PUMP REPLACEMENT: I� / State Work Done _ <br /> PUMP .REPAIR: / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> iDescribe 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 of1the well anal-notify them before puttingthe well in use.... Ttie above <br /> information is true to the best.-of_m k owled�ge�,and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A!p':FINAL 'TSPECT <br /> SIGNED moi. `° TITLE _ ,- <br /> C IM.jr LAAW PLOT PLAN ON REVERSE -SIDE) <br /> FOR DEPARTMENT_ USE ONLY ` <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE R-12�-Z � _ <br /> ADDITIONAL COMMENTS: �. <br /> r PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE �f 7 <br /> _ , <br /> E H 1426 Rev. � 1-74 2M =__j_ ,. _ . <br />