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{ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FO1 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209;) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�/ �3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) - <br /> L Application is hereby made to the San Joaquin" Local Health District for a permit to construct <br /> 1 and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and. theR^ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS E pr i �J� CENSUS TRACT <br /> Owner's Name leove7 Phone <br /> Address / City _ <br /> Contractor's Name License l o aej Phone <br /> TYPE OF WORK (Check) : NEW WELL 1 / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 0SEWER LINES +PIT PRIVY " <br /> SEWAGE DISPOSAL FIELD " ' CESSPOOL/SEEPAGE PIT /O® OTHER �^ <br /> PROPERTY LINZ-JYPRIVATE DOMESTIC WELA36-_l'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPEE O.F WELL CONSTRUCTION SPECIFICATIONS (v <br /> Industrial «' Cable Tool. Dia. of Well Excavation <br /> Domestic%private 4 Drilled Dia, of Well Casing <br /> Domestic/public§.x `=` :Driven Gauge of Casing <br /> Irrigation } "r Gravel Pack Depth of Grout Seal �A ¢" <br /> -Cathbdic Protection •Rotary Type of Grout " <br /> Disposal Other L <br /> `,� � Other Information <br /> �� �- ^oma-�e�.`"' L.►•�; _ <br /> Geo szca �: Surface Sea]. Installed By: <br /> PUMP .INSTALLATION: Contractor <br /> TYperof,Pump r� H.P. <br /> PUMP REPLACEMENT: ,, / / State Work.Dane <br /> PUMP .REPAIR: /,f/ State Work Done <br /> j DESTRUCTION OF WELL:;f° Well/biametei Approximate Depth <br /> f Describe P4aperial and• Pr cedure l <br /> [ I hereby agree to comply with all laws and regulations of the San Joaquin Local 4iealth District <br /> r <br /> and the State of California .pertaiffing 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 /> F WELL DRILLERS REPORT of the well and notify them before putting. the. well in use.. . The above <br /> information is true� to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION._._ <br /> SIGNEDL _ iTL;E <br /> (DRAW PLOT PT/AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY.- <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ TDATE <br /> `� <br /> [. ADDITIONAL COMMENTS: <br /> PHA II OUT INSPECTION P S II INAL INSPECTION <br /> INSPECTION BY DATEINSPECTION BY DATE l' <br /> f <br /> 07.7 _ 2M <br />