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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 -7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 a_?oa C /: . ' j ENSUS' TRACT <br /> Owner's Name Ali) 14 R Phone <br /> Address /� t� City <br /> Contractor's Name -► License PhoneQ� <br /> _-_ --- ,r--__'__•_— �_� ---�� .. -�., . �..-.�._ .- -- � Ems... �— --_..« .� ..� -.. ..- .- __ _.� _� .�. �...��--- — .� � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR _ PUMP REPLACEMENT <br /> Ober C-7 r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a <br /> PROPERTY LINE - PRIVATE bOMESTIC WELL PUBLIC DOMESTIC WELL _ <br /> INTENDED USE V 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 r <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: yContractor ,+ , <br /> - - _- Type of 'Pump _ - - H.P. . <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: IVI State Work Done ADD " Atep <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 thewell in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FO A GROUT INSPECTION <br /> PRIOR TO GROUfi AN A F AL INSPECTION. <br /> SIGNED T`w TITLE <br /> i(DRAW PLOT PLAN ON REVERSE SID } <br /> } ! s .•. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ic <br /> APPLICATION ACCEPTED' BY DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II-GROI-M INSP''ECTION HA EW/FIN4 INSPECTION ( 7 <br /> INSPECTION BY -'i ' DATE INSPECTION BY DATE <br /> E H 7426'- i2as�- , 7 7G b, /7 _ t <br />