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SAN JOAQUIN LOCAL :HEALTH DISTRICT <br />" FO - ,OFFICE USE: 1601 E. Hazelton Ave'. , Stockton, Calif. <br /> Telephone : (209) 466-6781 ��J) ��JJtt_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9d` -'7� ,Z <br /> THIS PERMIT EXPIRES 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 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 CENSUS TRACT <br /> r <br /> Owner's NameZI PI 110 11, 11K <br /> Phone <br /> Address <br /> City <br /> Contractor's Name Im 0 A <br /> a License # gp/�Phone r` <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL DEFPEN RECONDITION /_/ DESTRUCTION /7 _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> OtherCO <br /> DISTANCE TO NEAREST: SEPTIC TANK /1.L,1/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL�LFIELD !+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 i <br /> Domestic <br /> /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 Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, . . <br /> PUMP REPLACEMENT <br /> / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C 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 Y4 :k <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />,TELL 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 />'RIOR TO GR TINC AND . F1412L INSPEC ION. <br />'IGNED " <br /> TITLE <br /> ( W PL T PLAN ON JEERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />'RASE I n <br />,PPLICATION ACCEPTED BY DATE <br />►DDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION PHASE III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY L DATE . <br />,,E H 1426 Rev. • 1-74 b/77 2M <br />