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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, 'Cali£. <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 <br /> (Complete In Triplicate) <br /> Application is hereby made to the inn 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 /> f County Ordinance No, 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6068 Amsu. ,R1 CENSUS .TRACT <br /> Owner's Name , Phone <br /> Address AI.A City '_413 12)22 j,24 .Olv <br /> Contractor's Name z1a &0 License pjp Phone �7 <br /> TYPE OF WORK (Check); NEW WELL /? DEEPEN '/ RECONDITION / _f _DESTRUCTION. / f. <br /> PUMP INSTALLATION J / PUMP REPAIR/? PUMP REPLACEMENT <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 9 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 b1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> = <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 In€ormation <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump 4 H.P. <br /> PUMP REPLACEMENT: . / State Work Done U R <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 GROILTING AND A FINAL INSPECTION. <br /> SIGNED ic TITLE <br /> DRAW PLOT- PLAN:ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' Z Q' <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE III FINAL:INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE Lrl <br /> E H 1426 Rev. 1-74 h/75 2M <br />