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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 4 <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 11, (Complete In Triplicate) <br /> f 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 Joaquin Local Health District. <br /> 1 � <br /> JOB ADDRESS/LOCATION /D 1 CENSUS TRACT <br /> Owner's Name <br /> Phare <br /> P'� - � <br /> ; ) � <br /> Address ✓ City ' <br /> Contractor's, Name License �� �/'�! Phone <br /> 1 � <br /> ' TYPE OF WORK' (Check) : NEW WELL f / DEEPEN / I RECONDITION_/ / DESTRUCTION - 97 <br /> % <br /> f PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled:;. .�.r. Dia: -of-Well 'Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal T. <br /> Cathodic Protection Rotiary Type of Grout <br /> Disposal 01 her Other Information <br /> Geophysical Surface Seal Installed By: <br /> ' PUMP INSTALLATION: Contractor •, A <br /> I Type of Pump-^* 3 H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> � A , � <br /> iPUMP .REPAIR: "State Work Done - <br /> - <br /> DES TRUC -A roximAe Depth <br /> TION OF WELL: Well[Diameter pp p <br /> f 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 wellin use. The above <br /> information is true to the,best ofimy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> :PRIOR TO G TING AND A FNAL SPE TION. <br /> SIGNED L <br /> TITLE �� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) --- <br /> ? FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE g t-'7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , 71 DATE - 'J <br /> 1177 - -- 2M <br /> F -u 1A1)A Rosy- 1.-7L - - <br />