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s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOFirOFFICE USE: 11601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;S <br /> z THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / .7-97,E <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. 1.862 and the Rules and Regulations of the- San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> �i <br /> Owner's Name �� Phone <br /> Address - City <br /> 6 5.4 01) <br /> Contractor's Name _ License # PZ Phone - [1 <br /> NA <br /> TYPE OF WORK (Check): INEW WELL q DEE PENL/Y RECONDITION! <br /> ' f J DESTRUCTION /_7 <br /> PUMP INSTALLATION /7-7puMP REPAIR J7 T PUMP REPLACEMENT 17 <br /> i other .� <br /> fW oil <br /> DISTANCE TO NEAREST: SEPTIC TANK '_ SEWERILINES 111 PIT PRIVY <br /> ,. ria. �. <br /> SEWAGE DISPOSAL FIELDS ! CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - .PRIVATE DOMESTIC-WELL` - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF,:WELL_ ICONSTRUCTIOY�.sSPECIFICATIONS <br /> Industrial _ Cable Tool \ ,A% Dia. of Well Excavation • lz_) <br /> _ ^ <br /> Domestic/private, ' Drilled 1 Dia. of ,Well Casing <br /> Domestic/public Driven: --_. "� --Gaugej6 <br /> } Irrigation 'Gravel Pack Depth of -Grout. Seal.� <br /> Cathodic-Pro tection— -=Rot.ary�-- .-.Type of-Gibut= <br /> Disposal H Other Other Information <br /> ^Geophysical t Surface Seal. Installed By. Q <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP .REPAIR: /� State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter -Approximate Depth <br /> j 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 anew 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 ANDIRA FINAL INSPECTION. <br /> SIGNED M TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I c� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 6z LIZ <br /> PHASE IIIEGROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE E INSPECTIONTy <br /> - DATE 7.f` <br /> ti E H' 1426 Rev. 1 74 1-74..2M. .�- <br />