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r w } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Stockton Calif. <br /> Ave. , , <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No; <br /> 76 +793 P <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued p2-� <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sun 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 Regula ions of the San Joaq n Local Health District. <br /> JOB ADDRESS/LOCATION ENSUE TRACT <br /> Owner's Name Phone 6,1 4y— <br /> ll <br /> Address / ` City <br /> Contractor's Name ��[ ' z License 4���c�.� Phone2 <br /> TYPE OF WORK (Check) : NEW WELL / ? f fD / / <br /> . PUMP INSTALLATION/pi- PUMP 'REPAIR-/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK /- /,I 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 �1 <br /> Industrial 4.- Cable Tool Dia"."of Well,Excavation /V <br /> t_-Domestic/private ' Drilled. Dia. of Well Casing <br /> Dome stic/public Driven f Gauge of Casing <br /> Irrigation Gravel Pack ' Depth of Grout Seal <br /> Cathodic Protection Rotary Type.of. _Gr.out-' _ <br /> Disposal , Other Other Information �r <br /> f Geophysical r f Surface Seal Installed BX: <br /> PUMP INSTALLATION: <br /> - Contractors ` <br /> Type of Pump H.P. �C <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: / / State Work Done . . . . . . <br /> UES•TRUCTION 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 /> aftez completion of my work on a new well, I will furnish the San Joaquin Local Health District's <br /> t 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 FOR A 'GROUT INSPECTION <br /> PRIOR TO GRO SING AND A FINAL INSPECTION. <br /> I SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDENI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY • DATEe2obc <br /> ADDITIONAL COMMENTS: <br /> P E II G UT INSPECTIOR PHASE,141/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BYDATE 3 �.r <br /> R H 169ti <br /> ,0­ 1_7A <br />