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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 /> Z APPLICATION FOR WELL� CONSTRUCTION OR PUMP PERMIT Permit No. <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 made in compliance with San Jo4quin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION U3 CENSUS TRACT <br /> Owner's Name LL L S S Phone <br /> Address City <br /> a <br /> C Contractor's Name <br /> LOr-L , @ License �� Phone 6 Z~s R <br /> t <br />' TYPE OF WORK (Check) : NEW WELL/g . DEEPEN / / RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br />` Other,±/ / „• <br /> DISTANCE TO NEAREST: SEPTIC TANK d '"'SEWER LINES )fol + PIT PRIVY <br /> SEWAGEtDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> I NDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial f q Cable Tool. Dia. of Well Excavation /Q <br /> Domestic/private 1 Drilled Dia. of Well Casing �iZ <br /> Domestic/public 'I Driven Gauge of Casing <br /> Irrigation ! avel Pack Depth of Grout Seal <br /> Rotary Type of Grout {�iE ! <br /> Cathodic Protection ,..� Y — <br /> Disposal ± i '� .�j Other _ f� Other Information + <br /> Geophysical v-9 Surface Seal Installed B <br /> iPUMP INSTALLATION: contractor „A H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT /p / State Work Done _ <br /> ------- <br /> PUMP .REPAIR: / / .State Work Dane” <br /> E <br /> 'DES•TRUCTION OF WELL: Well. Diameter Approximate Depth " <br /> Describe Material and Procedure a 2 <br /> . I hereby agree- to complyiwith 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 SanjJoaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notifythem before putting the- well in use.. The above <br /> information is true to the best of my knowledge and belief. I WIL. CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING AND FINAL INSPECTION. . <br /> SIGNED } TITLE W <br /> {DRAW._PLOT PLAN ON _REVERSE. SIDE) . <br /> j <br /> FOR,:DEEARTMENT.�USEt ONLY, <br /> PHASE I f DATE <br /> APPLICATION ACCEPTED BY ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTIINSPECTIONp ! Y PHASE III/FINAL INSP TION :`�n: <br /> DATE d •� 0 INSPECTION BY DATE <br /> INSPECTION BY — <br /> u 1 L9 uay. 1-74 <br />