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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> } , Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued )->f 7G <br /> (Complete In Triplicate) <br /> Application is hereby made tb� 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 ', Le <br /> / <br /> d NSUS TRACT <br /> Owner's Name #N. ''1 <br /> A/ Phone r..y <br /> 1 } <br /> Address 4:Z� - <br /> 61W---- 4! A&.CJZAM&&Z22 ZED City ' <br /> Contractor's Name License # y Phone�eZ-S 97 <br /> i. <br /> TYPE OF WORD (Cheek) *. NEW WELL /7 DEEPEN /7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION '/ / PUMP REPAIR-/-7 PUMP REPLACEMENT 17 <br /> Other / / I <br /> DISTANCE TO NEAREST SEPTIC-TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT�V - .F OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Q <br /> Industrial F Cable Tool Dia. of Well. Excavation 4 <br /> Domestic/private i Drilled, Dia, of Well Casing ; <br /> Domestic/public ;I Driven Gauge of Casing �I <br /> Irrigation A Gravel Pack Depth of Grout Seal <br /> Cathodic Pr_otecLion . 1 Rotary Type of iirout._.. - <br /> Disposal ,I Other Other Information z <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. - <br /> PUMP REPLACEMENT: / / Stite4Work Done <br /> PUMP .REPAIR: - , - <br /> --/_-/-•;State=WorkwDone T .,..�. . <br /> DESTRUCTION OF WELL:.,. Well. Diameter Approximate Depth.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 <br /> WELL DRILLERS 'REPORT. of the well and notify theta 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 /> I PRIOR TO ROUT G-Aa ECTION. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SID <br /> FO <br />! PHASE I DEPARTMENT USE ONIY <br /> APPLICATION' ACCEPTED B DATE <br /> jADDITIONAL COMMENTS: <br /> PHASE II:'GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /-XA -741( <br /> I. E H 1426 Rev.' 1:.74w,,,,ae . h/7q 2M �' <br />