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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR(OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - ' Telephone: (209) 466-5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��lv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rule and Regulations of he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI CENSUS TRACT <br /> Owner's Name Phone �7 <br /> Address <br /> �� &4611CZ Ci <br /> Contractor's Name &ff2trzLicense t�lc�3 Phone ( --� <br /> TYPE OF WORK (Check): NEW WELL/PrDEEPEN /? RECONDITION /? DESTRUCTION /? <br /> PUMP INSTALLATION /k PUMP REPAIR /77 PUMP REPLACEMENT /7 <br /> Other j/% "- <br /> DISTANCE TO NEAREST: SEPTIC TANK �� EWER VNES 1 -SIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PI-T-IYV- 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 Ile ofor <br /> stic/private Drilled Dia. of Well Casing .1r <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout S al <br /> Cathodic Protection. teary Type of Grout _ <br /> Disposal Other Other Informat on p. <br /> Geophysical 00 S ac Seal Installed By: Q �' <br /> PUMP_ .INSTALLATION: Contactor <br /> . ' Type of Pu H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /_7 State Work Done <br /> ES•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 /> infm on is true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR G UTING AND ION. <br /> SIGNED TITLE ,. <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> P <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PWf II GROUT-INSPECTION PHAS I /FTN INSPECTION <br /> INSPECTION BY DATE 7,157:_U-71 INSPECTION B DATE /-/e- 7 <br /> ~E H 1426 Rev. 1� 6 1 WeAU i- 1-74 2M <br />