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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 <br /> Application is hereb (Complete 'In-Triplicate) '. <br /> y. made to the San Joaquin Local Health th .D <br /> and/or install istrict for. ..a .permit to .construct <br /> r, e work herein described. This application is made in compliance- with Sari Joaquin <br /> t. County Ordinance No. 1862 and the,Rules and Regulations of the San Joaquin Local Health D#strict. <br /> JOB ADDRESS/LOCATION 9' <br /> j CENSUS•TRACT - - <br /> Owner's Name3 <br /> . Phone 6 <br /> Address o�oZoZ 6 c1 �. � . <br /> Contractor's Name <br /> License o 02 7'9p Y d .Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION' /? 4 <br /> PUMP INSTALLATION -/-/ PUMP REPAIR P <br /> Other UMP REPLACEMENT 17/% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.- <br /> SEWAGE <br /> INES - <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> 4 <br /> E PIT <br /> PROPERTY LTNE -- PRIVATE DOMESTICSWEOLJSEEPA�UBLIC DOMESTICTHER <br /> INTENDED USE TYPE OF WELL WELL' <br /> Industrial ...�,. w_,�.v.;,.�,4.-q.,.,.� CONSTRUCTION SPECIFICA-rij S <br /> --- Cable-Tool-- -- --.Dia;-ef-We1`l Excavation- gn <br /> Domestic/private DrilledI Dia.xof-Well Casing <br /> �— Domestic/public �� Driven Gau 4 <br /> Irrigation t ge of Casing : <br /> Gravel Pack Depth of Grout .Seal <br /> Cathodic Protection ' Rotary Type. o -Grout <br /> Disposal Other Other Information <br /> Geophysical <br /> t Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump ': r <br /> 3 A.P. <br /> PUMP REPLACEMENT: • / / State Work Done <br /> .g 7�. Work Done <br /> ` Al .1 - <br /> I3E&TRUCTION OF WELL:• Well `Y <br /> Diame t`er <br /> Describe Material. and Procedure App ox ate Depth <br /> -- .�— <br /> T hereby agree to comply'i,with-all',laras' and regulations of the San Joaquin Local health District <br /> and the State of California pertaining to or regulating well"construction.: Within FIFTEEN DAYS d <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 mya..knowled and be <br /> PRIOR TO GR ING AND FI INSPECTION. g' lief' I WILL CALL FOR A GROUT INSPECTION <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> t <br /> W ATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS,• ,. DATE e <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /,l..I DATE .. <br /> �— ' <br /> E <br /> H"1426' ..:Rev. 1-74- <br /> „ <br />