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1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO <br /> } .f FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;�4L_ 5�.2ea <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued/0_1 - <br /> o Al CAr-vW� (Complete In Triplicate) <br /> Application is hereby made t'a the San Joaquin.Loca1 Health' District fcr 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 Regul tions of the Sin Joquip Local He th District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone 3� WO <br /> Address <br /> " City <br /> Contractor's Name License !i L! G.�11 Phone 3r�8 33 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/� RECONDITION /? DESTRUCTION <br /> PUMP INSTATION / / PUMP REPAIR /� PUMP REPLACEMENT �T <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Ca <br /> PROPERTY LINE r 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 0 Ala <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> f_1 State Work Done , <br /> PUMP ,REPAIR: /7 State Work Done <br /> ES•TRUCTION 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-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED <br /> IV (DRAW PLOT PLAN ON REVERSE SIDE <br /> ,er FOR DEPARTMENT USE ONLY <br /> PHASE I. <br /> DATE <br /> APPLICATION ACCEPTED BY d" <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE Q. ` INSPECTION BY r DATE,; <br /> CO <br /> E Y 14 Rv. 1 <br /> 26 e . -74 1 <br />