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4 FF—OF.'. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 7.601 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 ISSUED6-/asjo <br /> (Complete In Triplicate) Date Issued <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 /> JO A�DD�RESS/LOCATION <br /> �` �' 1 4 Af h L 1 i1dv^1b f"S TRACT <br /> Owner's Name ANC gs L'Q rV <br /> Phone <br /> Address _ a �� 4p j' - <br /> City <br /> Contractor's Name <br /> License �� <br /> TYPE OF WORK (Check) : NEWWELL/ DEEPEN '/7 RECONDITION /_7 DESTRUCTION f? <br /> PUMP INSTALLATION /�f PUMP REPAIR _7 PUMP <br /> Other REPLACEMENT f <br /> J/ / — <br /> DIST,l1NCE 7FO NEAREST: SEPTIC TANK EWER LINE ' <br /> SEWAGE DISPOSAL FIELD PIT PRIVY i <br /> PROPERTY LINE - PRIVATE DOMESTICSP OLEEPAGE PIT OTHER <br /> INTEiNDE�U USE �L PUBLIC DOMESTIC WELL <br /> TYPE; OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool <br /> ome:stic/private Dia. of Well Excavation <br /> Drilled Dia. of Well Casing f <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary T <br /> Disposal ""'-- Type of Grout -� �, <br />—Geophysical Other Other Information " <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 4 ', <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: • - <br /> I / State Work Done ' <br /> PUMP .REPAIR: <br /> / State Work Done- <br /> r <br />)ES•TRUCTION OF WELT,: Well. Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I herebyagree p Y 'r <br /> gree to comp 1 with all laws and regulations of the San Joaquin Local Health District <br /> knd the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a � <br /> 4ELL DRILLERS REPORT of the well, and notify them before putting the.-well in use.... The above <br /> Lnformation is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />'RIOR TO GROUTI G D NAL INSPE ON. 1 <br /> iIGNED <br /> TITLE <br /> — DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br />.PP IL CATION ACCEPTED BY <br /> DDITIONAL COMMENTS., DATE /,2 i20 "7,l <br /> PHASE II GROUT INSPECTION <br /> NSPECTION ]BY PHAS ]CII FINAL INSPECTION <br /> DATE INSPECTION BY <br /> DATE <br /> E H 1426 !_ , <br /> 1-Y ?74?Re . "�`r� <br />