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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOFIfOFFICE 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 Date Issued /�_7,� <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of >the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . 9 V 19 �R , ���� -- CENSUS TRACT <br /> Owner's Name I AA j Phone <br /> Address City SSCgI DA <br /> Contractor's Name T: -( 14,) License <br /> pQPhone - p <br /> TYPE OF WORK (Check): NEW-WELL, /77, DEEPEN/--7-—RECONDiTI-ON-/?~-DESTRUCTION /'-j <br /> AL ^~ <br /> PUMP INSTLATION / / PUMP REPAIR / / PUMP REPLACEMENT %7 <br /> Other /j — <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. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> „_— Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary _ -- - --Grout' <br /> _Y ----Type- <br /> Disposal g,,. �� , Other _ Other Information rfi s <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION:, � Contractor �� .°°.° _.,_•_ <br /> � ,� <br /> Type of Pump i H.P. <br /> PUMP REPLACEMENT: / / State Work Doiie <br />-PUMP '.REPAIR: _ ­17y`' <br /> State Work Done_ �" d� � i_ b�.,., <br /> ES-TRUCTION OF WELL: Well Diameter 'e $ <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Isocal 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 notifythem before <br /> putting.. the. well in.use.. The. above <br /> information is true to the best-ofmy:.knowledge and belief. I WILL�.CALL POR GROTTY`*fINSPEC£ION <br /> PRIOR TO GROUTIG D IN INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> ` <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> � -^ <br /> AP-LCATION'.ACCEPTED BY �+ <br /> '� DATE /0 <br /> ADDITIONALICOMMENTS: <br /> PHASE II GROUT" INSPECTION PHASE'. I ./F A INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE , <br /> I E H 1426 .-"Rev. 1-74 _, 'Al <br />