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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> F'OIx�OFFICE USE: <br /> 1601E Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781. � <br /> r + 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 Realth District for a permit to .construct <br /> and/or instar. the work herein described. This applic- aiion is made in compliance with San Joaq . nf <br /> County Ordinande No. 1862 and the Rules and •Regulations of the San Joaquin Local Health District <br /> 34 � fid/ , CENSUS TRACT <br /> JOB ADDRESS/LOCATION .- �C _Gr! �G�n,�, ,. <br /> Owner's Name _ �7 �1 r ,,� 9�0 l Phone PJS - 93 <br /> Address City '- <br /> Contractor's <br /> ity 'Contractor's Name - �ti . License # Ll LJ L3Phone ?S <br /> TYPE OF WORK (Check) : NEW W' ELL '/-7 DEEPEN '/ J RECONDITION / f DESTRUCTION /-7 <br /> PUMP INSTALLATION f-1 PUMP REPAIR !47 PUMP REPLACEMENT /7 <br /> Other <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER CJ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q <br /> Industrial Cable Tool Dia. of Well Excavation n <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sealj <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed Bir: <br /> ',PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />`-PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR " "'~ / f�'S to Ed Work Dane <br /> ff <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t 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 /> J WELL DRILLERS REPORT of the well and notify them before putting the..well. in.use.... The above 3 <br /> 1information is true to the-best-of- my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR-TO GR TING ANDA FINAL INSPECTION. t <br /> k SIGNED TITLE -7 A-ate--� <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) �— ---� ; <br /> S <br /> FOR DEPARTMENT USE -ONLY <br /> I PHASE I L <br /> APPLICATION ACCEPTED BY DATE . <br /> ADDITIONAL COMMENTS: <br /> r PHASE II G UT INSPECTION ;:� PHA E III FINAL INSPECTION <br /> CT <br /> INSPECTION BY DATE INSPEibN BY DATE .3 <br /> E H 1426 Raw_ 1-7A -- <br />