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V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2S`-.soli <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a2- -75-x' <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct �t <br /> and/or install the work herein described. This appi.ication is made in compliance with San Joaquins <br /> County Ordinance No. 1862 and the Rules and Regulations of the San 'Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 n CENSUS TRACT + <br /> Owner's Name Phone <br /> Address <br /> City a <br /> Contractor's Name � �� .� /_Qo2 License # Phone " G <br /> TYPE 1OF WORK (Check)-. NEW WELL '/-7 DEEPEN '/-7 RECONDITION /-7, DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR -/7 PUMP REPLACEbEff- 17 <br /> j, Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> E PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> q, INTENDED USE TYPE OF WELL .. CONSTRUCTION SPECIFICATIONS <br /> I; 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 Type of Grout + <br /> -j Disposal. Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> is <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: State Work Done _ Q4e - 1 <br /> PUMP "REPAIR: / / State Work Done. i <br /> DESTRUCTION OF WELL: //'107ell Diameter Ap.;pr5ximate Depth <br /> Describe.Material nd Procedtte <br /> 94 <br /> 11 'hereby agree to comply-with a1 aws and regulations the an Joaqu n ocal 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 /> inforination is true to the-best of my;knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR`TO GRPUTING AND A F N PECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ^' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE, 1 <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> S. <br /> PHASE II GROUT INSPE TON P AL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE - <br /> �i' A 1/.7� n_-- •s i 1. h.' nae <br />