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Q SAN JOAQUIN LOCAL HEALTH DISTRICT LL <br /> FOA!'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46b-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T4t-,r <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued/ <br /> In Tri� <br /> (Complete' ' P plicate) <br /> Application i 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 Ordinance No. 1862 .aid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ~ <br /> CENSUS TRACT <br /> Owner's Name , Phane 14` <br /> Address -' - <br /> �� City <br /> i" 'Conttactor.'s Name Y <br /> ,.. License. Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /� �1fECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION <br /> Other / / PUMP REPAIR / / PUMP REPLACEMENT% 7 <br /> } /j -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> G PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ► <br /> INTENDED USE TYPE OF WELL GONSTRUCTION SPECIFICATIONSmmaa j <br /> Indcistrial #1D <br /> able Tool Dia. of Well Excavation 1 <br /> Domestic/private rilled Dia. of Well Casing �? <br /> Domestic/public riven Gauge of Casing E <br /> rrigation ravel Pack Depth of Grout Seal d <br /> Cathodic Protectionotary Type of Grout — _- <br /> Disposal ther Other Information rt . <br />` Geophysical Surface Seal Installed By: ! J{r; <br /> PUMP INSTALLATION: Contractor <br /> + Type of Pump �,�_\k ! - :`'�' $.P. f j. r <br /> PUMP REPLACEMENT: <br /> j/7 State Work Done _ # y <br /> PUMP `REPAIR: -/ <br /> !&E-S; RUCTION OF WELL; Well Diameter <br /> Approximate Depth.` <br /> Describe Materiatid Procedure <br /> t '• :, <br /> ,I hereby agre—et o 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 FIITEEN !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-•w- -true-to-the-.-best--of.-my--knowledge and belief:—I--WILI;CAUI�"FOR A G�tOUT-INSPECTION <br /> PRIOR TOG ING A A INSPECT-ION: 1 �t _ _ <br /> SIGNED . TITLE #+ <br /> a (DRAW PLOT—PI AN ON REVERSE SIDE Newt- E <br /> PHASE I !I .FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> DATE O .y <br /> ADDITIONAL COMMENTS: ;� t <br /> PHASE II GROUT INSPECTION "' PHAS IIF AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> YE H 1426 <br /> 'Rev. 1-74Y 01'_74 7u <br />