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- IV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> 7�-7871 : <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 u m„1 f� _!iQv,,_ 1y,� CENSUS TRACT -Iz�p <br /> Owner's Name <br /> Phone _ P3 P - 76T,3 <br /> Address I fe 7 L!�+,4 <br /> City <br /> Contractor's Name License 1f ' <br /> LoPhone a <br /> TYPE OF WORK (Check): NEW WELL /7A DEEPEN /X7 RECONDITION /_7 DESTRUCTION f7 <br /> ALt <br /> PUMP INSTLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST:- ; SEPTIC TANK b ; SEWER LINES G PIT PRIVY <br /> "SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER + <br /> PROPERTY,LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL i <br /> INTENDED USE TYPE°OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial '.' �/ Cable Tool Dia. of Well Excavation <br /> !_ Domestic/private —�t- Drilled ,Dia: 'of Well CasingDomestic/ f <br /> Irrigation <br /> Dz3v'en'' Gauge-of Casing /� J <br /> Irrigation Gravel Pack .`Depth of Grout Seal / r <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information:.' <br /> Geophysical r_ _ Surface Seal Installed BY: <br /> PUMP INSTALLATION. Contractor,, J <br /> Type-of-Pump, _ - - H:P. ._.. - -- <br /> _ - <br /> _ <br /> PUMP REPLACEMENT* State Work Done <br /> PUMP '.REPAIR: / 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 I� <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 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 {4 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> TITLE � A <br /> (DRAW PLOT PLAN ON PLR <br /> FOR DEPARTMENT USE <br /> PHASE I ONLY <br /> APPLICATION ACCEPTED BY L DATE9 <br /> TIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P 2 NAL INSPECTIO <br /> ECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 h/75 2M <br />