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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160 , Hazelton Ave. , Stockton, Cal: <br /> %01- <br /> Telephone : (209) 466-6781 (/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L S-L' 1C eel ���{�, I.r",CENSUS TRACT <br /> i <br /> Owner's Name a l p I-��t1` k Phone VjYj"- @ 4= I <br /> R; City <br /> Address t C� S . ��. K eai. �i I_ <br /> Contractor's Name k I+c wc.t 14„ j; ce' License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /7 <br /> ,✓�,t„� PUMP INSTALLATION �/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / L <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 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 /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /0 5 <br /> Type of Pump 1 H.P. -74) <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 <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 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 rrxlilx -' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE /-7Sr-7 <br /> APPLICATION ACCEPTED BY / <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE I/FIN INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F N 149A nom., 174 <br />