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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFs;OFFICE USE: 1601 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 ISSUED Date Issued i�X79 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sart Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name e 1 tU' 3j <br /> Phone <br /> Address "e.. <br /> city. Sid$ d� <br /> Contractor's Name <br /> License. aCY�Phone <br /> TYPE OF WORK Check): <br /> NEW WELL '/? DEEPEiLFT RECONDITION 1-7 DESTRUCTION /-7 <br /> PUMP-INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other % / _ <br /> DISTANCE TO NEAREST: I SEPTIC TANK SEWER LINESPIT 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 <br /> Domestic/private Drilled Dia. of Well Casing-, i <br /> Domestic/public Driven Gauge of Casings <br /> Irrigation Gravel Pack- Depth of Grout <br /> Cathodic Protection Rotary e F i <br /> - Disposal � __� Other Type of Grout , <br /> �� Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor. , y r <br /> r Type Of Pump <br /> A.P. <br /> PUMP REPLACEMENT: State Wo.`1 ate <br /> rk Done ! <br /> PUMP IREPAIR: � , StateM1`+Work- <br /> Done , -c <br /> I T. <br />)ES-TRUCTTON OF WELT;s Well Diameter{ ' �' <br /> � Approximate Depth <br /> Describe Material and Procedure rW._ '�`--- <br /> L 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 `donstruction. Within FIFTEEN DAYS <br /> after completion of my work ona new well, I will furnish the San'Joaquin Local Health District_ a <br /> JELL DRILLERS-REPORT_of-the-well -and-.notify-them-before-putting.-the..uiell. in.use. . .The above <br /> Lnformation is true .to the•best�of, my. knowledge and belief. I WILL CALL FOR 'G <br />'RIOR TO GROUTikr-ANg..4 IMIAL INSPECTION. ROUT INSPECTION <br /> UUNED <br /> TITLE . z& <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br />'RASE I <br />►PP IL CATION ACCEPTED BY <br /> JDDITIONAL COMMENTS r DATE ' L kx <br /> PHASE II GROUT INSPECTION PHA II INAL INSPECTION <br />.NSPECTION BY DATE _ INSPECTION BY 5 ._DATE <br /> E H 1426 Rpir. 1_7A <br />