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t <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Aizelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FO.R WELL' CONSTRUCTION OR PUMP PERMIT Permit No. <br /> -`I 1 S PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a7-7t <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 ismade in compliance with San Joaquin <br /> County' Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. ( CENSUS TRACT <br /> ! 3 <br /> Owner's Name / Phone <br /> Address City <br /> FLicense 4 Phone <br /> Contractor's- Name /L/�G�•C � _- <br /> 1 <br /> TYPE OF WORK (Check) :' NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION ;;7 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> e <br /> Other <br /> DISTANCE TO NEAREST: t SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL;/SEEPAGE PIT -"--OTHER Q <br /> PROPERTY LINE/-4PRIVATE DOMESTIC WELL PUBLIC -DOMESTIC WELL S <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial # Cable Tool Dia, of Well Excavation _/`e <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of CasingZaZ <br /> Irrigation Gravel Pack Depth of-. Grout Seal 47,61V104- <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : <br /> i PUMP INSTALLATION: Contractor } <br /> Type of Pump / H.P. <br /> i PUMP REPLACEMENT: . / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> T" <br /> , DESTRUCTION 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 perta2nfing--to-or-regulating�wel3��construction. Within FIFTEEN DAYS <br /> t 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 t e well. and notify them before putting the .well in use. The above <br /> information is true A he best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI <br /> SIGNEDTITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> �. ,'ti, , •.. z. .: ,� ',FOR DEPARTMENT, USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3d <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA�111N,� NSPECTION <br /> INSPECTION BY DATE INSPECTION BYATE ---5-15- <br /> oK 1/,r f yil- _1 /7 <br /> v y i. <br /> 11r_ ---- 1 17 1 - I,1--7-_ <br />