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CA SAN JOAQUIN LOCAL HEALTH DIStRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &-,G-1' 34,J <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued6 <br /> (Complete In Triplicate) V06 <br /> Q—rro - 7-p- <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 ' rdinance, No. 186nd the Rules and Regulations of the San Joaquin Local Health District. <br /> -FV IN <br /> JOB ADDRESS/LOCATION( � <br /> L fNSUS TRACT <br /> Owner's' Name y ,` Phon j ' <br /> 4 Address.' /-= r <br /> j it City- <br /> Contractor's Na g��. f License qf,j Phong <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN '/7 RECONDITION /7 f <br /> DESTRUCTION / <br /> PUMP INSTALLATION PUMP REPAIR,/-7-PUMP REPLACEMEj <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a <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 lit <br /> Industrial C� able Tool Dia. of Well Excavation <br /> f—Domestic/private Drilled Dia. of Well Casing <br /> D8mestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack Depth of Grout Seal d' ' <br /> Cathodic Pr_otect_ion Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. Z-e <br /> PUMP REPLACEMENT; . / / State Work Done <br /> PUMP 'REPAIR; State Work Done <br /> DESTRUCTION 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-of my-knowledge and belief. I WILL CALL. FOR A GROUT INSPECTION <br /> PRIOR TO GRO IN AND A FINAL INSPE_ N. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE i <br /> FOR DEPARTMENT USE ONLY <br /> /J <br /> APPLICATION ACCEPTED BY U� - DATE <br /> ADDITIONAL COMMENTS: <br /> PRAS9 II ,GROUT INSPECTION PRASNAL INSPECTION <br /> INSPETION BY f DATE J.Z �/- INSPECTION B DATE <br /> E 1426 Rev. 1-74 r h/75 2M <br />