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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE.*OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone :p (209) 466-6781 77-- 9.3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 09— THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued `" - <br /> V�, P1 (Complete In Triplicate) <br /> Application is hereby de 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ��_ CENSUS TRACT <br /> Owner's Name E E Phone - �p <br /> Address 3 / �, .L <br /> . EN►anr City _cam-�nnf. <br /> Contractor's Name421 <br /> Y 2&V gla 14411License <br /> Zf/6/ Phone -"s <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/—/ RECONDITION RECONDITION / / DESTRUCTION /_7 s <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other {{i <br /> -- 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK ZZQ SEWER LINES` r <br /> �/p'-f PIT PRIVY �--- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE�Q 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 ` 12 <br /> Dia. of Well Casing <br /> Domestic/public Driven # Gauge of Casing , <br /> Irrigation 'Gravel- Pack Depth of Grout Seal U J .-� <br /> Cathodic Protection Rotary,- Type of Grout t <br /> Disposal O'ther— Other Information <br /> Geophysical Surface Seal Installed By: <br /> ,'UMP INSTALLATION: Contractor 1 <br /> Type of Pump <br /> PUMP REPLACEMENT: ,./_/ ,State Work_. Done ' + <br /> PUMP -REPAIR: - ` /}/_State Work-Done' <br /> DESTRUCTION OF WELL:, Well Diameter t <br /> y . Approximate Depth <br /> Describe Material and Procedure <br /> 11 <br /> I hereby- <br /> agree to comply with all laws and :regulations of the San Joaquin Local Health District j <br /> and4the 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 tru' 'to t ' }i a t of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T RO G D A N I <br /> SIGNED. TITLE g " <br /> (DRAW PLOT PLAN ON REVERSE SIDE) (J <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I - <br /> APPLICATION_AC CEP.T-EDwBY PATE <br /> ADDITIONAL COMMENTS: I <br /> `PHASE II' GROUT-INSPECTION' PHASE IU <br /> / INAL P1CTION <br /> INSPECTION BY DATEL��7 1 INSPECTION BY <br /> E H 1426 "Rev. 1--74 1177 WI& f <br />