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SAU JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1 ��FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:P (209). 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> M I <br /> 7s-l/is <br /> d THIS PERMIT E7tPIRE5 1 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 her described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Losal Health District. <br /> JOB ARMWLOCATION ,� l r _. _.. _y �I�` IAl <br /> CENSUS TRACT <br /> oe <br /> Owner's Name 0z orzA <br /> Phone <br /> Address /D , Z /�� �-�GGC. Cit <br /> Contractor's Name License,,�.. <br /> _ 4iE9 one �- <br />` TYPE­OF WORK (Check): NEW WELL . DEEPEN -/_7 RECONDITION /? DESTRUCTION f7 <br /> PUMP TNST LATION `K PUMP REPAIR REPLACEMENT 17 <br /> Other / 7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK��o +SEWER LINESf-_D O PIT PRIVY 47 <br /> SEWAGE 'DISPOSAL IELD C �"Q Q � <br /> ESSPOOL/SEEPAGE PIT -OTHER <br /> PROPERTY LINPRIVATE DOMESTIC WELL��tUBLIC DOMESTIC WELL�L'r�`� j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t `Cable Tool Dia. of Well Excavation <br /> Domestic/private gilled Dia. of Well Casing1 <br /> omestic/public i i Gauge <br /> ge of Casing A,� fl <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection j Rotary Type of Grout _�.�.. <br /> Disposal t Other Other Information <br /> Geophysics] . < . _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump r H.P. <br /> -PUMP REPLACEMENT: / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> iES'£RUCTION OF WELL: Well Diameter <br /> Approximate. Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlall 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 is true to the,best of- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR. TO GROUTIN FIN S ION. <br /> SIGNED' TLE <br /> r RAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEP T USE ONLY <br /> - <br /> APPLICATION ACCEPTED B - DATE <br /> ADDITIONAL,COMMENTS: <br /> PHASE Ii GROUT INSPECTIONSE III FIN INSPECTION <br /> INSPECTION BY DAT INSPECTION BYATE 7 <br /> E H 1426 Rev. 1-74 + <br />