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/ o � SAN JOAQUIN LOCAL HEALTH DISTRICT - ---- l <br /> FOPi•r FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> s� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //_.2 2- <br /> � <br /> (Complete In Triplicate) <br /> Application is hereby made to the Safi 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. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> I <br /> Owner's Name mo i .0 ra! Phone <br /> Address D City 'P06i0G/`-,,_� <br /> Contractor's Name License # A3 rx4Phone L-A.7 4. <br /> TYPE OF WORK (Check): NEW WELL/-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7 PUMP REPLACEMENTbK-7 o , <br /> Other / / -- Nj <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 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 <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. Surface Seal Installed By: <br /> f , <br /> f. PUMP INSTALLATION., Contractor <br /> a , <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ;REPAIR: /-7 State Work Done <br /> 2ES1TTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply w fhWTll 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_compleCion 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 the before puttingthe..well in.use.. The above <br /> informaiion 'is true to- the-best of- my knowledge an belief. 1 WILL CALL FOR A GROUT INSPECTION <br /> i PRIOR TO ING AND-3A FIN SPE N <br /> SIGNED ITLE ' <br /> P.L TON MVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �— �✓� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> DATE �`�,� -7,51 <br /> ;� 1 E H 1426 • 'Rev. 1-74 1-74 2M <br />