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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160 <br /> FOF�;OFFICE USE; 1 E.. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �9 <br /> THIS PERMIT E7CPYRES. 1 YEAR.FROM*DATE ISSUED Date Issued <br /> } (Complete .In. Triplicate) a <br /> Application is-hereby`made to the San.Joaquin Local Aleal,th. Di,strict..,for a permit to construct <br /> and/or install the work herein described. This Application,i.s made ,An.compliance with San Joaquin <br /> County Ordinance No.' 1862 and the Rules and Regulationgof the .San Joagain.Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name .3 � � - - <br /> Phone ESQ 7 1 o _ <br /> Address _ Sp <br /> # City ' LS_ a4- <br /> Contractor's Name .,1sn A) - License. #-?75 Phane - C17 <br /> TYPE OF WORK (Check): NEW WELL -/7 DEEPEN -/7 <br /> -7. RECONDITION / f DESTRUCTION /_7 <br /> PUMP INSTALLATION /� PUMP REPAIR PUMP REPLACEMENT <br /> Other L/� . <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. 1of Well Excavation <br /> _ Domestic <br /> Domestic/private Drilled Dia. `of Well Casing ; �] <br /> /public � Driven Gauge of 'Casing <br /> g� <br /> Irrigation . �..�:-. `..._.T_- <br /> g Gravel Pack Depth of .Grout Seal,a, <br /> Cathodic Protection - Rotary Type of Grout <br /> DisposalI Other Other Information' <br /> Geophysical <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> i 4.- <br /> rw Type of Pump <br /> j H.P. <br /> PUMP REPLACEMENT: .: / / State Work Done l <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter .---- r u�+� <br /> Describe Material and oced a Approximate :Depth <br /> I hereby agree to comply withs'all laws and regulations of the 'San Joaquin Local Health District <br /> and the State of California pertaining to-or.:regulating iYell:'rcons-tructioii: : Within FIFTEEN DAYS <br /> after completion 'of my work on a new well, 1 will.furnish the .San• JoAquiA LocaLHealth District a <br /> WELL DRILLERS REPORT of -the well and notify'--them before putting.-the.'.w6l1-"in use:.. -The above ' <br /> information is true to the best of my. kno�wXedge_gnd belief I WILL"CALI, F R'A GROUT INSPECTIO <br /> PRIOR TO GRO ING AN F AL INSPECTION.R E <br /> SIGNED S <br /> + TITLE <br /> DRAW PLOT PLAN. ON REVERSE SI <br /> # <br /> PHASEI FOR `DEPARTMENT USE ONLY <br /> , � . .. ' <br /> APPLICATION ACCEPTED BY k <br /> DATE <br /> ADDITIONAL COMMENTS i <br /> PHASE II GROUT INSPECTION P iI N INSPECTIO <br /> INSPECTION BY DATE INSPECTION <br /> By//, DATE <br /> E '9'1426 .M Rev.a --7k <br />