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�( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•rOFFiCE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No?-:Z L&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /7 <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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��� Lt /%I" ,�, , / CENSUS TRACT <br /> Owner►s Name / j' �/(/ jt/ Phone '?-3/- G '13 <br /> Address 1 H /, ' City .STOc.,Y Q,y <br /> Contractor's Name C.4,/�1?/� Leg QIP GU, License � 7L � Phone <br /> - G2-5517 <br /> TYPE OF WORK (Check) ; NEW WELL / DEEPEN "/? RECONDITION /-7 DESTRUCTION /j <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT %f <br /> Other j/7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ,/ SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT W4 OTHER <br /> PROPERTY LINE /0 PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ./0 <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 - °V Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.P. <br /> PUMP REPLACEMENT: j//7 State Work Done _ <br /> PUMP.REPAIR: L7 State Work Done <br /> ES•TRUGTION 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-beat of.,. my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO U INC AND A F NAL INSPECTION. <br /> SIGNED f TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMEN : <br /> P RO INSPECTION PHASE-11I FINAL INSPECTIO <br /> INSPECTION BY DATE / W INSPECTION BY DATE 1 <br /> E H 1426 VevX 74 1-74 2M <br />