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t •^yWrt- -• _- ti 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FFO 'OF,FICE. USE: . — , 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone : (209) 4666781 <br /> r .APPLICATION FOR WELL CONSTRICTION OR PUMP PERMIT "Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to• the San Joaquin Local -Health District for a permit to construct <br /> and/0r :install the. work,herein described. This application is made in compliance with• San� Joaqui:n <br /> i County Odinance No. 1862 and the Rules ,and Regulations of the Sari Joaquin Local Health District. <br /> d. : L� <br /> �4 <br /> JOB ADDRESS/LOCATION (..tI `' Q,-r �,/ CENSUS. TRACT ..- - <br /> Owner's Name Phone <br /> Address s (� / City <br /> I.Lk Contractor's Name �� �, 4 �� �, ' Ll i�PAJC N T- .... _Lice-n-se;,#,7 Phone <br /> TYPE OF WORK (Check) �NEW„WELL_ , _DEEPEN. . ..RECONDTTTON-1-77 _DESTRUCTION •f�..-_ _ ti,. <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `' PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1' <br /> .S• f , <br /> PROPERTY LINE - PRIVATE DOMFSTIC WELL " =PUBLIC DOMESTIC_ WELL — <br /> INTENDED USE -TYPE OF-WELL, CONSTRUCTION SPECIFICATIONS <br /> us <br /> trial CAb'le.'Tool Dia. of Well Excavation 14 AICL <br /> stir/prx�va eg T Drilled' ' Dia. of,,.W611 Casing <br /> t`T DomesCie%publi'c Driven } Gauge,:f Casing ("' <br /> ' " Irrigation G -aver Pack Dept0of Grout Seal �4 <br /> Cathodic Protection Mary Type -bGrout C <br /> Disposal I Other Other Information r <br /> - Geophysical - - , Surface Seal, Installed .B : . <br /> PUMP ,INST-AIL ATION: Contractor r c /0 <br /> Type of Pump r H:P. O <br /> ' PUMP .REPLACEMENT: j,/�,/ -State; Work Done <br /> PUMP REPAIR: *` :44 --State -Work-Done <br /> DES-TRUCTION OF. WELL: Well Diameter:. . -Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complly 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 4 <br /> after ,completion of myl work on.,,a_ne,w,_well, .I' ill-.furnish;the San Joaquin Local Health District,.'a <br /> ? WELL DRILLERS REPORT 'af the well and notify them before putting thewell in use. The above <br /> information is true toll the best. of my knowledge, and belief. I WILL CALL FOR A GROUT INSPECTION, <br /> ' PRIOR TO GROUTING AND A FINAL-INSPECTION:. <br /> SIGNED. _ TITLEVC1 <br /> i� '(DRAW-PLOT PLAN ON REVERSE SIDE)., <br /> _ - FOR DEPARTMENT USE .ONLY. <br /> PHASE I <br /> APPLIGAT.ION ACCEPTED BY DATE <br /> ADDITIONfi�L=--COMMENTS: I� <br /> ' r= PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY "F' DATE INSPECTION BY - DATE <br /> ^ - <br />