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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE 'JFFIE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ,R <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 8 /L �v 5a,r� /`h� 1 Ap to 1'l/4a � kp <br /> His PERMIT EXPIRES 1 YEAR FROM DATE ISSUED —FO- Ae-- Date Issued <br /> f� (Complete In Triplicate) <br /> Application is hereby made to thelSan 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 anti he Rules and Regulations of the. San--Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -;CENSUS TRACT <br /> Owner's Name Phone2?y_�//� <br /> g <br /> Address Q.�� ,' City <br /> J <br /> Contractor's Name License # �Phone �' - <br /> 1/17 <br /> TYPE OF WORK (Check.) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION /7 ra <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Ocher <br /> DISTANCE TO-NEAREST.; SEPT-.0 TANK/©D0-_ . -SEWER--L-INES --w_P1T_..P.RIVY' <br /> SEWAGE DISPOSAL FIELD [ CESSPOOL/SEEPAGE PIT �" "' OTHE-R _ - G- <br /> PROPERTY LINE - P_RIVATE DOMESTIC WELL PUBLIC DOMESTICWELL <br /> INTENDED USE j TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable ,Tool Dia. 'oi, Well Excavation <br /> Domestic/private Drilled - Dia, of'Well Casing �! <br /> Domestic/public rr Driven - y Gauge of. Casing '� /Qq. _ <br /> Irrigation Gravel. Pack XDepth of Grout Seal '� <br /> Cathodic Protection Rotary _,iType_.of Grout <br /> Disposal Other Other Information _ N <br /> Geophysical ; ! - Suface Seal Installed B <br /> 6 <br /> i, Q <br /> PUMP INSTALLATION: ; Contractor <br /> Type of Pump R H.P. <br /> PUMP REPLACEMENT: /�/ State Work Dane <br /> PUMP .REPAIR: / / State Work Done <br /> DES-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 ofmy knowledge And belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTME ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Q DAT 43, <br /> ADDITIONAL COMMENTS: 54 <br /> PHASE II GROUT INSPECTION PHASE—III—/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> \ <br /> 9_H_1426 Rey-1-74 77 _ 2M <br />