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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOk.'_OFFICE USE -1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued LA92177 <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 LOCATIONc�` <br /> ADDRESS/LOCATIONCENSUS TRACT <br /> Owner's Name <br /> Phone ' ' <br /> Address � M e / <br /> , City . Zl_ . <br /> i Contractor's Name / License # - Phone <br />, TYPE <br /> r �" <br /> i <br /> TYPE OF WORK (Check) : NEW WELL,''/j/� DEEPEN / / RECONDITION /7 DESTRUCTION /-J <br /> ._ . <br /> PUMP INSTALLATION / �/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NNEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE-DISP05AL FIELD iCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> t 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 r,_-Depth -of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed By: • <br />! PUMP INSTALLATION: Contractor <br /> TYpe,.of Pump H.P. <br /> PUMP REPLACEMENT: LV � State Work Done er <br /> i <br />,'PUMP .REPAIR: / State Work Done _ <br />, ES-TRUCTION OF WELL: Well Diameter Approximate Depth ' <br /> Describe''Material and Procedure <br /> i <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 /> rafter 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 /> rinformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROIN NG AND A FI AL INS ECTION. <br />, SIGNED fir- TITLE, - J 1 <br /> RA PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br />:APPLICATION ACCEPTED BY t DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II ORO _" ION PHASE I/FI L Z14SPECtIjF <br />('INSPECTION BY ATE INSPECTION BY DATE 777_7-77 <br />` E H 1426 Rev. 1-74 1I <br /> F <br />