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•,� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE .OFFICE USE: Lam`' 1601 E. Hazelton Ave. , Stockton, Calif. s <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z-8'Z&) <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �Z <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 - 12 CENSUS TRACT <br /> Owner's Name ' Phone <br /> Address J 21 ke �0City <br /> Contractor's Name License # Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL .J / DEEPEN '/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION f / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY V <br /> SEWAGE DISP SAL 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 ,2 <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 InformationI <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <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 's true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO NG AND,. INSPECTION. <br /> SIGNED f TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> it PHASE I C� <br /> APPLICATION ACCEPTED BY ' Y DATE U <br /> ADDITIONAL COMMENTS: <br /> F S I GROU INSPECTION P SE /FIN INSPECT ON <br /> E INSPECTION BY DATE INSPECTION BY DATE <br /> Z Z D ! 1177 2M <br /> 9 N 1G9A D. 1_71, <br />