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OSAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> ' FOFSrOFFICE USE: 1601 E. Hazelton Ave. , 'Stockton,kton, Calif. <br /> Telephone: ` (209) ._466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I r ,� <br /> THIS PERMIT EXPIRES I YEAR-;FROK DATE ISSUED Date Issued / <br /> (Complete In Triplicate) t =. <br /> APPliciBtion is hereby made to the San Joaquin Localj1ealth District for a permit to construct <br /> and/or install the work herein described. This application is wade 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 <br /> ` ' ''' CENSUS TRACT ... <br /> Owner's Name 7 <br /> Phone <br /> Address S _ _ ti ..- <br /> C Cityor <br /> Contractor's Name 1 s AJ <br /> License # Phone <br /> TYPE OF WORK (Check): NEW WELL -7 DEEPEN '/_ T T ` <br /> � RECONDITION /_� ,DESTRUCTION % j <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT <br /> Other4/ / <br /> DISTANCE TO NEAREST: SEPTICTANK ' -.� SEWER LINES � <br /> '�"`--SBWAGE�ISI'U51AZ�'IEI.D PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OAR � <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL tlti <br /> ' INTENDED USE TYPE OF WELL t CONSTRUCTION SPECIFYCATIONS <br /> Industrial f Cable Tool Dia. -o£ Well Excavation <br /> Domestic/private ! Drilled Dia. of Well Casing <br /> Irrigation <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout , <br /> Disposal <br /> Geophysical Other Other Information" ~- <br /> f --"--- <br /> Surface Seal Installed B : `�77 <br /> PUMP INSTALLATION: <br /> Contractor <br /> Typeµof Pump - t H.P. <br /> y <br /> ...,.......�,.,,,-,.,..,..._.ti�, S <br /> PUMP REPLACEMENT: State Work Done j <br />­PUMP _--=4_/ T state work�`Done _ Y <br /> ES.rTRUCTION OF WELL. Well Diameter ~ <br /> Describe Material and Procedure y Approximate Depth <br /> I hereby agree to comply withlall laws and regulations of the San Joaquin Local Health <br /> and the State of California pertaining to or regulating iaal construction. Within FIFTEENtrict DAYS <br /> after completion of my work on a new well, I will fur`nis`h the_San�Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. thweZl ia.use, <br /> above <br /> information is true to the_�best of my knowledge and belief. V WILL CALL FOR A GROUT The <br /> INSPECTION <br /> PRIOR'TO GROUTI G AND A 'FIN' 'INS P. Cr30N. s - , <br /> SIGNED <br /> } fTViLE <br /> ----F DRAW-PLOT.-.PLAN-ON REVERSE SIDE <br /> PHASE I A <br /> R DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS:1 ' DATE G �_ <br /> PHASE II G OU "I P T N PHASE III FINAL INSPECTION <br /> INSPECTION BY AT INSPECTION BYK <br /> DATE <br /> E H 1426 Rev. I-74 <br />