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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,-OFFIC-E 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 IssuedN <br /> ' (Complete In Triplicate) <br /> Application is h+ereby 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 Alkjv CENSUS TRACT <br /> Owner's Name , A1_._T2[�,1 J�+�O ,���- 25_4.., .,. ._._. Phone _ ��?::.M <br /> Address <br /> city _,4g".'ej & <br /> Contractor's Name License 4Qo ..Phone <br /> y <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION 1-7i <br /> PUMP INST`ALILATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 k <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �99 <br /> PROPERTY' LINE - PRIVATE DOMESTIC WELL kja- � PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE -OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool t Dia, of Well Excavation <br /> Domestic/private Drilled t4 Dia, of Well Casing <br />� ..-Domestic_ .,:,, ..--4 -�.....-- g ---'g -- - -- <br /> /public '� - Driven--"'- _ Gau- e of -Casiri- <br /> Irrigation Gravel Pack; Depth of Grout Seal <br /> Cathodic Protection Rotary Type ,of Grout <br /> Disposal Other 0_ther` Information <br /> L-' <br /> Geophysical <br /> Surface Seal Installed By: v ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 4 <br /> r - <br /> { <br /> PUMP REPLACEMENT: / / State. Work Done <br /> PUMP .REPAIR: - <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate DepthT�____ <br /> Describe Materia 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 DAIS <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 FOR A 'GROUT INSPECTION <br /> PRIOR TO ROUTI A F,11NAL IWECTIeN. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION 7PHASE III/FINAL INSPECTION <br /> INSPECTION BY ^� DATEINSPECTION BY DATE ,f-,, G P <br /> E H 14?F, , 7/177 _ 2M i, <br />