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=' / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: f/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. zz--/D g-)-P , <br /> THI91PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g lS J) <br /> (Complete In Triplicate) <br /> Application is hereby made tAhe 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 /> .1 ! <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone ' /z .I <br /> Address City <br /> i <br /> Contractor's Name � 4GU license �� �`(�ePhone —UPJ <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /_/ DESTRUCTION /-7 w <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / ,I <br /> ;I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> E INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private 3 Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection it Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical ', Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor Al <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: � State Work Done <br /> I or <br /> PUMP7REPAIR: [-7 State Work Done <br /> !DES.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 /> V 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 INSPECTI N <br /> PRIOR TO GROUTIN AND A FINAL INSPECT ON <br /> SIGNED ' TITLE <br /> I (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ' PHASE I /��-7 7 <br /> APPLICATION ACCEPTED BY DATE 7— <br /> :ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FI L�DAT <br /> ECTION <br /> INSPECTION BY DATE INSPECTION BY - -'� <br /> 1/17 _. 2M <br /> R. N IL9A Rav_ 1-74 <br />