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�✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORiOFFICE USE: 1601 E. Hazeltone'Ave Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T_ rt-,Tj4 jo <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> t rc �t d9 LFc✓��c 4 -g; (Complete In Triplicate) c-r —130�v <br /> Application is hereby-made- 1 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 SUS TRACT <br /> :Owner's Name <br /> Phone 3 c� -s—,sq-j) <br /> Address , 4A <br /> City` <br /> Contractorts Name -� � ._ License #A._137 Phone <br /> TYPE OF WORK (Check): NEW WELL/,7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION /� PUMP REPAIR / PUMP REPLACEMENT /_f <br /> Other 'J`" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> °c <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 i Drilled Dia. of Well Casing <br /> Domestic/public. Driven ._ . ... „Gauge of•,Cas,ing <br /> Irrigation- " ' i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout <br /> Disposal ` 1 _Other . , . � <br /> Geophysical Other InformationSurface Seal Installed B : <br /> PUMP INSTALLATION: Contractor' <br /> Type 6f Pump a <br /> H.P. <br /> PUMP REPLACEMENT: / / tate Work Done <br /> -PUMP '.REPAIR: State,Work Done.. p , <br /> _ - _ <br /> ES;TRUCTION OF WELL: Well Diameter <br /> 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 INSP <br /> PRIOR TO GROU NG ANDA INALiINSPECTION. <br /> SIGNED ECTION <br /> TITLE <br /> t <br /> t .� DRAW PLOT PLAN QN REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE I FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ,DATE f <br /> ;E.H 1426 Rev. 1-74 <br /> . , 1_74 gar <br />