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led SAN JOA4 UIN LOCAL HEALTH DISTRICT <br /> F0R;OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �/c� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a:/_ -�6 j <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 ad�-S CENSUS TRACT <br /> Owner's Name Phone -. /�9(� <br /> Address City <br /> Contractor's Name1 <br /> License # `�p�� Phone �2g j-4" <br /> YTYPE OF WORK (Check) : NEW WELL /)(7 DEEPEN '/_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTAL TION J / PUMP REPAIR -/� PUMP REPLACEMENT /7 <br /> Other /_7 . . . . . <br /> DISTANCE TO'NEARESTV SEPTIC TANK SEWER LINES PIT PRIVY } <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELL" 1 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _k Cable Tool - ,Dia. of Well Excavation <br /> Domestic/private Drilled ,'Dia. of Well Casing <br /> -_ Dome.s.tic/peabl�c Driven ;'.. Gauge of Casing g ,� <br /> $ \t <br /> Irri ation G-r--awl-P Bei-t-h-�of- 1 <br /> --- -GSea14= - -- - - - <br /> -- - - - �_ <br /> Cathodic Protection Rota.r. . - T" a of Groutt 1 <br /> Disposal Other ```4 Other Information a' <br /> Geophysical Surface Seal Installed- By: y< 4 6 <br /> PUMP INSTALLATIONS Contractor W. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REFAIR: .-State Work Done <br /> DESTRUCTION 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 /> ,end 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 puttingthe..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 GROUTING AND A.FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE700, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE <br /> ADDITIONAL'COMMENTS: j <br /> PHASE IT CROnT INSPECTION PHA FtN INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATEAg <br /> V n 1 A79 b.... 1-9/ 1,17t 7M <br />