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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS <br /> —70FFICE 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 'l 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 Drdinance No.. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATJON ��,, , , f�y�- � fir, Q CENSUS TRACT <br /> Owner's Namet Phoned ^r/ �S <br />{ Address, w .C: /L L(J: ' f City -- <br /> Contractor's Name License #16, )-323 Phone 3 .[ � <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN /7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION I I PUMP REPAIR-A& PUMP REPLACEMENT /? <br /> Other / } . <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DIS€'OSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r PROPERTY•LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL' CONSTRUCTION SPECIFICATIONS �\ <br /> ' Industrial A- sw Cable Tool, Dia. of Well Excavation - 1 <br /> -. Domestic/private Drilled Dias. $of Well Casing <br /> Domestic/public Driven. Gaugeeof Casing <br /> Irrigation --Gravel Pack - Depth ,of Grout Seal 4 <br /> Cathodic Protection, Rotary kJ Type "a Grout <br /> Disposal z' Other . Other Information <br /> Geophysical ,Surf ace Seal Installed-B a -. <br /> E ---- '- --- - <br /> PUMP INSTALLATION-.� <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: .' / / State Work Done <br /> PUMP ,REPAIR:. / State Work Done -ail <br /> : <br /> i <br /> DES-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 /> 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 i true to the-best -of.,my..knowledge.and belief. I WILL CALL FOR A GROUT INSPECTION' <br /> PRIOR TO GRO NG ' D A . AL INSP CTION. j <br />+ SIGNED } TITLE <br />�. (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR-'DEPARTMENT USE ONLY <br /> PHASE i -r / <br /> APPLICATION.ACCEPTED BY DATE J j ! 't- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �-7-7`7 <br /> E H 1426" Rev. 1-74 r` h/75 2M <br />