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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> p 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 ;1-19-_2X1 <br /> (Complete In Triplicate) <br /> Application is hereby made toithe 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 Jaaquinl <br /> County Ordinance No. 1862 and t2p Wes rulations of a San Joaquin Local Health District. <br /> :YOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name S Phone Q I <br /> Address City C • <br /> Contractor'a Name IV.,P -+ L�� License #,IQg5 Phone <br /> 5 _ <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN/� RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION F�'PUMP_REPATR / I PUMP REPLACEMENT <br /> L Other <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER L�NES --SPIT PRIVY <br /> SEWAGEfDISI'OSAL FIELD —CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY` LINE - PRIVATE DOMESTIC WELL`-" PUBLIC DOMESTIC WELL �y <br /> INTENDED USE TYPE OF +WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> 4--Ilo-mestic/private a Drilled Dia. of Well Casing S �/ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Grave-1-.-Pack, Depth of Grout Soal <br /> Cathodic Protection <br /> otar 1_ Type of GrouC <br /> c��" y <br /> -� Other Other Information P. , <br /> Disposal ' - ;- � _ <br /> Geophysical a C r Surface Seal Installed B , <br /> k <br /> PUMP INSTALLATION: Contractor ' <br /> Type of PuA X I_ H.P. <br /> i PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: /_7 State Work Done—- - <br /> RES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure r <br /> I hereby agree to comply with all laws and regulations of the `SaniJoaquin Local Health District <br /> and the State of California pertaining to` or regulating well construction. Within TIFTEEN DAYS <br /> after completion of my work on a new well;. I_ will_furnish_-the_San-J.oaquin_Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well. in.use.. The above <br /> infor ation is true to the best-of my .knowledge and belief. I WILL CALL FORA GROUT -INSPECTION <br /> PRIORROUTING AND A I <br /> SIGNED`_ y`= 1 ,.4 4 TITLE <br /> 4 ,, (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I } 6� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> F It 0 INSPECTIONHAS IIF INSPECTI <br /> INSPECTIONBY DATE INSPECTION. BY DATE <br /> 't <br /> J. <br /> H ,1426 Rev a 1- ' F f 1-74 2M <br />