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R - <br /> 5AN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOF�:OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. 1 <br /> Telephone: (209)"-466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pe.rmi�� No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ' <br /> ISSUED Date Issued <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin <br /> Local Health District for a permit to .construct <br /> and/or install the work;�herein described. This application is made in compliancel.J'with San Joaquin <br /> le a Regulatio f the Sast 'Joaquin Local health District. <br /> County Ordinance No. 186 and the Ru <br /> JOB ADDRESS/LOCATI `� � � -- CENSUS TitACT ' <br /> _ Fhoneq <br /> r <br /> I Owner's Name ;F <br /> �� Cit <br /> f'.Address <br /> nonem" <br /> i Contractor's Na License <br /> TYPE OF WORK (Check): :ice WELL. ,(—[ DEEPEN '/� RECONDITION / DESTRUCTION <br /> PUMP <br /> INSTALLATION '/ / PUMP RE <br /> P_AIR /N' Yom' REPLACEMENT <br /> i� <br /> Other / / <br /> DISTANCE TO DEAREST: SEPTIC TANK SEWER LINES PIT PRIVY IN. G <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> t PROPERTY LINE - PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC IIWELL C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS N <br /> s Industrial _ Cable Tool Dia. of Well Excavation iM <br /> Datsestic/private:' _— Drilled Dia. of Well Casing iM <br /> Gauge of Casing <br /> Driven �M <br /> � Domestic/public �: il <br /> Irrigation Gravel Pack- Depth of Grout Seal <br /> d� <br /> Cathodic ProtectRotary y Type of Grout <br /> Other Information <br /> Disposal Other <br /> Geophysical Surface Seal Installed 'B : <br /> PUMP INSTALLATION: Contractor <br /> H.P. - <br /> Type of Pump <br /> f State Work Do , �M <br /> PUMP REPLACEME . r e <br /> PUMP `.REPAIR• J Stiate�Work Dona! -91 <br /> It eAlt <br /> DESTRUCTION OF WELL: i Wel1. Diameter <br /> {/ Approximate Depth _ <br /> Describe Material and Procedure i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin LocallHealth District <br /> and the State of California pertaining to or regulating well•'constructian. Within FIFTEEN DAYS <br /> ".h .y <br /> after completion of my work on a new we11,. I <br /> will furnish the San Joaquin Lacal�� Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting-the.-well. in.use�:. The above <br /> ♦ information is true Co the-best:of. my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND['A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN, 6N REVERSE SIDE <br /> F FOR DEPARTMENT USE ONLY <br /> [ PHASE I , .. DATE` <br /> APPLICATION ACCEPTEDBY <br /> ADDITIONAL COMMENTS: II <br /> PHASE Ili GROUT'.INSPECTION PHA II F NAL INSPE N <br /> INSPECTION BY +M DATE INSPECTION BY 1l`Y■nRTE _, <br /> 47 <br /> Z7 2M. <br /> R A 1 A76 now 1:,74 <br />