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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:1 P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I 22 2z 3G) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> G 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 411V 7 <br /> I CENSUS-TRACT <br /> Owner's Name J�p C � p U ' <br /> Phone <br /> o�7 / <br /> Address �. � /C~� o ���- �,. A <br /> City (5;�&N, <br /> Contractor'-s Name � � Lice a # Phone <br /> DEEPEN RECONDITION <br />` TYPE OF WORK (Check) ; NEW WELL _ <br /> / / /_% DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /? <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC.WEL-L .. PUBLIC DOMESTIC WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECTFICATTONS <br /> Domestic/private <br /> Industrial �- Cable Taol Dia, of Well Excavation <br /> Domestic/public � <br /> Drilled Dia. of Well Casing <br /> Driven Gauge. of ..Casing <br /> Irrigation - :Gravel�Pack Depth of;"Gtout Seal <br /> Cathodic Protection Rotar <br /> .Disposal y TYPE of Grout <br /> i Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of, Pum <br /> H.P. 4 <br /> PUMP REPLACEMENT: / -/ State Work Done - <br /> PUMP ,REPAIR: / ./ State Work Done <br /> DESTRUCTION OF WELL: We11-Diameter � =fes:'� Approximate Dep h /66 <br /> Describe Materi and Procedure <br /> I hereby agree to comply with all laws and � latio s of the San J quinfLocal 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 /> 4ELL DRILLERS REPORT of the well and notify rthem hef.ore putting the..well in use. The above <br /> information fs true to Ahe best of my knowledge and' b elief": I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO IMG AN FINAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> PLOT PLAN ON REVERSE SIDE) <br />'MASE I <br /> FOR DEPARTMENT USE ONLY M <br /> APPLICATION ACCEPTED BY DATE e <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II G TION PHAS INSPECTION <br /> NSPECTION BY j D INSPECTION BY DATE <br /> E H 1426 1-74 X7�7 <br /> -- <br /> Rev. i <br />