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SAN JOAQUIN LOCAL; HEALTH DISTRICT <br /> FOAjOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?'3 3 S <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Stealth 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 San Joaquin Local Health District. <br /> 7i� „ <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name _ Phone - 0 l <br /> Address �-_,__s_�.. <br /> City <br /> Contractor's Name LicensePhone 2J� <br /> TYPE OF WORK (Check): NEW WELL!' /? DEEPEN 17 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTAL, TION / / P�..REPAIR AT—PUMP REPLACEMENT <br /> — — <br /> Other ._ — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Ij <br /> V <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '— <br /> PUBLIC DOMESTIC WELL <br /> _INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial n �g.._ <br /> Cable Tool -.Dia. "of Well Excavation <br /> Domestic/private Drilled Dia. 'of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel -Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal Other Other Information <br /> Geophysical <br /> 4 Surface Seal Installed By_.-, <br /> _ R <br /> PUMP-INSTALLATION: Contractor'` <br /> yAeTof-Pu <br /> H.P. <br /> PUMP REPLACEMENT: — <br /> / °/ State Work Done <br /> k <br /> PUMP :REPAIR: -�.-y.,.I7- --State-Work Done <br /> ESTRUCTION OF WELL: Well Di + <br /> aster f 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'., J will_lfuinish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them -before pu <br /> tting.. the..well in.use.. The above <br /> information/4-s) true to the'best of my' ledge and ---belief.: I WILL CALL FOR GROUT INSPECTION <br /> PRIOR TOG IN AND 72AL INSPEC310N. r� <br /> SIGNED ►f .� . <br /> I ,l TITLE <br /> ILAMAW PLOT PLAN ON REVERSEsSIDE) > <br /> PHASE I FOR DEPART NT E ONLY. <br /> �. � <br /> APPLICATION ACCEPTED- BY _ _ � 9 ' yy +, <br /> DATE <br /> ADDITIONAL COMMENTS• , <br /> • a `:� .! :+ •`*-ter ,f" ?` .I <br /> PHASE II GROUT INSPECTION PHASE' III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY'-", DATE 26 <br /> 1E H 1426 Rev. 1-74 <br /> 1 _,, O. .. . - 11 . - 1-74 2M <br />