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SAN JOAQUIN LOCAL HEALTH DISTRICT �- <br /> FOE� OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .�J• <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 /> rind/or install the work herein described. This app3ication 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 . o <br /> P�PC�L R CENSUS TRACT' <br /> Owners Name Phone7 <br /> Address i <br /> City,' <br /> Contractor's Name License Wfj 7? Phone q� C`56r.G <br /> TYPE OF WORK (Check) : NEW WELL '/g DEEPEN '/-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR /7 PUMP REPLACEMENT 17 1 <br /> Other Ll <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK ZOO I <br /> 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 75P <br /> X Domestic/private Drilled Dia. of Well Casing �1 <br /> Domestic/Public zi ` Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout { <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump z ti H.P. <br /> PUMP REPLACEMENT: State Work Done ' <br /> PIM .REPAIR: /-7 State Work,'Dona 1 <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 TOG UTING ANDA AL INSPECTION. <br /> SIGNED TITLE_._ _ I <br /> DRAW PLOT PLAN ON REVERSE',.SIDE) <br /> FORD ARTMENT JJSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED `& k-" D �/CC? DATE 7L <br /> ADDITIONAL COMMENTS b3 <br /> PHASE II G OUT INSPECTIOi PHA I PE ON r <br /> INSPECTION BY .r "`" DATE INSPECTION BY DATE <br /> E H 142A V ft r 1—7C s_ /nr' ^%a <br />