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G.,dl SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A-2:Y_� LJ <br /> 7E-,2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date- Issued ,/7.3a-J� <br /> (Complete In Triplicate) <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Hea th District. <br /> ,TOB ADDRESS/LOC TION/ � � /4�ff 0* k T <br /> Owner's Name <br /> Phone <br /> Address City - _ <br /> A- <br /> Contractor's Name License � Phone N- <br /> TYPE OF WORK (Check): NEW WELL /TT--'EEPEN -/'7 RECONDITION /__7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / t V)KIR PUMP REPLACEMENT 7 <br /> J <br /> Other <br /> DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES PIT PRIVY <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 4---eMe Tool, Dia, of Well Excavation0z er � <br /> t—To—mestic/priv a Drilled Dia. of Well Casing <br /> Domestic/publ c Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> C thodic.Pro c io + .. Rotary Type of Grout 9 <br /> s - Other Other Information ' <br /> Geophysics Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `REPAIR_: /7 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 GRWTIW AND A FI INSPECTION. <br /> SIGNED .r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Z DATE- <br /> APPLICATION' ACCEPTED BY � � <br /> ADDITIONAL COMMENTS: <br /> PHAO E II T INSPECTION PHASE III/F" INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE o' �s <br /> E H 14'16,,Rev. 1-74 t - - - r <br />