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CO w-. SAN JOAQUIN LOCAL HEALTH DISTRICTFOT,1OFFIICC USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z��G <br /> (Complete. In Triplicate) * /0-15'- roo-13 <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 Health District. <br /> .JOB-ADDRESS/LOCATION S O u a A*t .,� p ek_ CENSUS TRACT <br /> Owner's Name Phone <br /> Address Y7- Ys p City <br /> Contractor'a Na �o«Jyp�� ` <br /> License #113 phone -A-- ?6 e; <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN -/_/ RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR 0 PUMP REPLACEMENT /-7 <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. Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed_ By: - -„ <br /> PUMP INSTALLATION. <br /> Contractor �� ^ <br /> Type of PumpH.P. [j <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `.REPAIR: /7 State Work -Done <br /> E&TRUCTION 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 ING AND A FINAL INSPE <br /> SIGNEDTITLE <br /> {D W PLO PLAN ON RSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE {D y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- B DATE 75 : <br /> 1 E H 1426 Rev. 1--74 ,, _ <br />