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i <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> F.OX OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D <br /> - ate Issued <br /> I (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> I 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 r • , '" AWUNSUS TRACT <br /> Owner's Name IrggF1 L Phone <br /> Address Ct ty ,; <br /> Contractor's Name J License # c2Wolo Phone <br /> TYPE OF WORK (Check) : NEW WELL `/-7 DEEPEN "/—/ RECONDITION /_7DESTRUCTION /7 <br /> i <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 i Cable Tool Dia. 'of We11_Excavation ' <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public I Driven Gauge of 'casing i <br /> Irrigation I Gravel Pack Depth of;-Grout Seal j <br /> Cathodic Protection ! Rotary Type of Grout"' <br /> Disposal i OtherOther Information <br /> ��Geop t sica��'�''>� -��••--Surf`ace Seams Inst`a]-7ed"B"t` <br /> PUMP INSTALLATION:� <br /> Contractor r" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:_ State-Work Done <br /> PUMP REPAIR: /_i�/State Work Done <br /> DESTRUCTION OF WELL: ; Well Diamet r��;> r 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 weil '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 the well- in use. The above <br /> information is true to the best of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION ' <br /> PRIOR TO GROUTIN D FINAL CNSPNCTION. <br /> SIGNED - ------ TiTLE-- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BYIr <br /> 44 - DATE <br /> ADDITIONAL COMMENTS: 41 <br /> PHASE II GROUT II49PECTTON PHASB II FINAL INSPECTION ' <br /> I <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> "•,2M <br /> E H 1426 Rev. _ -� _ � Z7 <br />