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SAN JOAQUIN LOCAL HEALTH DISTRICT -- - <br /> FOFirOFFICE USE: 16.01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9A$ J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �,2 s <br /> A (Complete In Triplicate) �+ (y I <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct 7 <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> 18 <br /> County Ordinance No. 62 and -the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1 ' �.��` CENSUS TRACT <br /> Owner's Name Phone <br /> P?G s� <br /> Address City <br /> Contractor's Name l License #,25.222 Phone .oW -141A y1 <br /> TYPE OF WORK (Check) : NEW WELL 22T DEEPEN/7 RECONDITION /_7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR J / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER pQ <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 / 2r <br /> y-*'bomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 10 <br /> Irrigation - Gravel Pack Depth of Grout Seal _0 .� <br /> Cathodic Protection a Rotary Type of Grout <br /> —Disposal _ OtherOther Information <br /> Geophysical _ Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor ..j <br /> Type of dump .t.�. H.P. a1 , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br />&ES;TRUCTION 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 Distract <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 j <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 I. <br /> PRIOR TO GROUTING ANDA )FIN . INSPECTION. <br /> SIGNEDTITLE `� <br /> ► DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �~ <br /> APPLICATION ACCEPTED BY rj DATE�Q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION J <br /> INSPECTION BY f DATE r / INSPECTION- BY w .� DATE <br /> E H 1426 Rev. 1-74 <br /> I-t42M <br />