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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE"OFFICE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -.Z75� <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 -Ja quin Local Health District. : <br /> JOB ADDRESS/LOCATION <br /> _1 .CENSUS TRACT <br /> Owner's Name • ' C� f <br /> Phone , <br /> Address City . <br /> Contractor's Name A,4 • License # Phone :�,?o7 <br /> L1 _111. <br /> TYPE OF WORK (Check)$ NEW WELL ' DEEPEN/_' RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION'-f/ PUMP REPAIR /? PUMP REPLACEMENT <br /> / f7 <br /> Other /� <br /> DISTICE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> .' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITOTHERl�<<'� !� <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USF. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. _ Cable Tool Dia. of Well Excavation zz� \ <br /> Domestic/private Drilled Dia. of Well Casing .� <br /> u_ ;,-Domestic/public _ ,. Driven -Gauge -of-Casing" <br /> _ Irrigations Gravel Pack Depth of Grout Seal �` <br /> Cathodic ProEe224 <br /> c,tion /L Rotary Type of Grout , F <br /> - Geophysical <br /> Other Other Information �- <br />_-,•�Ceophys ilial �- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor E <br /> Type .of Pump <br /> H.P. <br /> PUMP REPLACEMENT: L I <br /> / State Work Done - <br /> PUMP '.REPAIR; /? State -Work Done <br /> S TRIICTTON OF WELL s 4'l Well Diamear 4� Approximatepie th � <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 Californis' 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 />?RIOR- TOG UTiNGAND A INAL I PE. ON. <br /> SIGNED � <br /> D PLO PLAN ON RSE SII1E - -•��,-`�"' <br /> PHASE I R DEPARTMENT USE ONLY � <br /> APPPLICATiON' ACCEPTED By .. DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE TI GROUT INSPECTION <br /> CNSPECTION BY P IIF INSPECTION <br /> DATE INSPECTION B DATE ` <br /> E H 1426 <br />