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_ <br />- (o iltp ja 4 SAN JOAQUIN LOCAL HEALTH DISTRICT _.-. <br /> FORt'OFFI E 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 -S=7 <br /> (Complete In Triplicate) { <br /> Application is hereby made tolthe 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/LOCATION CENSUS <br /> TRACT <br /> Owner's Name 9. 1 , �t Phone <br /> Address . <br /> A/ �� �. . City <br /> Contractor's Name ��d License: �P oh ne <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN '/_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /g/ PUMP REPLACEMENT %7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL F �" <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �. <br /> Industrial j Cable Tool Dia, of Well Excavation (� <br /> Domestic/private i Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing �n <br /> - )C, Irrigation 3 Gravel Pack Depth of Grout Seal \� <br /> Cathodic Protection Rotary Type of Grout' „L V <br /> Disposal : Other Other Information <br /> Geophysical Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ”' H.P. 7-� --- <br /> PUMP REPLACEMENT: /7 State Work Done <br /> 3 <br /> PUMP ,REPAIR: State Work Done <br /> i <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 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 o my kno:jledgeand belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T UT NG D A FjPL-jNSP41VI0V.ji <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN 0 ERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /1?7i� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN IN PELT <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> s E H 1426 _ Rev. I-74 1-74 2M <br />