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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFx.OF ICE USE.• <br /> 601 E. Hazelton Stockton,Ave. , Calif. <br /> Telephone: (209) 466-6781 <br /> .F APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> TRIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (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 is 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 `✓ 1411 Al R o T.,rm m✓ 1 CENSUS TRACT ' <br /> t <br /> Owner's Name Ivar 0' Phone <br /> Address S u-) h 0- City <br /> Contractor's Name ] License # / y Phone <br /> �-706 <br /> TYPE OF WORK (Check): NEW WELL J-7 DEEPEN/7 RECONDITION f7 .DESTRUCTION /.j <br /> PUMP INSTALLATION / / PUMP REPAIR / T PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I ` Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing (^ ; <br /> 1--�Domestic/pu6lic--=- °>^'.Driven Gauge <br /> w Gau a �ofw.CasingIrri <br /> Irrigation t Gravel Pack am- <br /> I <br /> -Depth of-Grout <br /> Cathodic Protection I Rotary Type of Grout <br /> Disposal f Other 01 Other Information <br />:- Geophysical.; Surface Seal =Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ta <br /> Type of Pump <br /> ! H.P. <br /> PUMP REPLACEMENT: • / / State Work Done <br /> PUMP .REPAIR: <br /> -State Work Done V16 eZC1 . <br /> DE <br /> S,,TRUCTION OF WELL: "Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with -all laws and regulations of the an SJoaquin 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. Co the-best-of- my knowle nd belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INS I , <br /> ITLE �m ,f , <br /> RAW PLOT PLAN ON FRSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br />�— II <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GRM INSPECTION PHASE F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE 67/j�5- <br /> ._ <br /> E 9 1426 ,... Rev. 1-74 <br />