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SAN JOAQUTN LOCAL HEALTH. DISTRICT <br /> T� <br /> FOF 4FFTCE USE: /� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 1466-6781 <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 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 APEE L A ) 5- CENSUS TRACT <br />,;..,Owner's Name AAAAl Phony <br /> address /gam6 City �ca <br /> Contractor's Name License # a2 7CjO iAPhone 933Q—?o <br /> _ t <br /> "TYPE OF WORK (Check) : NEW WELL / DEEPEN- /—/.. '..RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / /_ _ 7. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> r <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 Dia, of Well Casing <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 Information <br /> Geophysical '-Surface Seal Installed BX: <br />..PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />'PUMP REPLACEMENT: / State Work Done ��� J .� <br />`.PUMP .REPAIR: / / State Work Done <br />;DE.S•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 we11- and -notify thein before putting the .well in use. The above <br />'information is true to the best. of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO G.R5KING AND IN4 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GRO T INSPECTION PHASE_III/FINAL INSPECTIONr <br /> INSPECTION BY DATE INSPECTION BY .r '. ,�,. /1D -E ry� <br /> E H 1426 Rev. 1-74 TIZ7 " 2M <br />