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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Ig� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereb 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. 18'62 -and the Rules and Regula o_ns of the San Joa uin Local Health District. <br /> ' 1 FL TW Sr�,v Ko(//- <br /> JOB ADDRESS%LOCATION -� �/ 3 � � �� ��C��yd- <br /> 0,0V c All, CENSUS TRACT <br /> Owner's Name Phone <br /> Address ? L City <br /> Contractor's Name le; ,� License #,VT' MbPhone _ 7ZT� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL_,AF DEEPEN / RECONDITION / / DESTRUCTION /7 _ <br /> PUMP INSTALLATION / PUMP REPAIR /_/ PUMP REPLACEMENT <br /> Other / / — <br /> i - <br /> DISTANCE TO NEAREST: SEPTIC TANK jp F SEWER LINES -PIT PRIVY_--,*- <br /> SEWAGE DISPOSAL FIELD , CESSPOOL/SEEPAGE PIT _-a_ OTHER <br /> PROPERTY LINE WrPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL '\? <br /> • INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �, <br /> Industrial Cable Tool Dia, of Well Excavation Al <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domesti . <br /> Irr /public Driven Gauge of Casing 6a ps'l, <br /> igation _ Gravel Pack Depth of Grout Seal fir- �1 <br /> Cathodic ProtectionRotaryType of Grout Cr....Q,ns - <br /> Disposal Other Other Information <br /> —Geophysical � Surface Seal Installed .S : � <br /> PUMP INSTALLATION, Contractor <br /> Type of Pump H.P. -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done <br /> — <br /> DES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 7 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 <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 GROUP INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECjeON. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I — <br /> APPLICATION ACCEPTED BY DATE 117T7 <br /> ADDITIONAL COMMENTS: l ~. <br /> PHAS II GR T INSPECT P SE4 /FI INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE / 7_2' <br /> Z��t 2M <br /> _ E H 1426 Rev. • x--74 0/77 <br />