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FO SAN JOAQUIN LOCAL HEALTH D <br /> � �o�usE: DISTRICT <br /> 1601 E. Hazelton Aire. , Stockton, Calif. <br /> Telephone: (209) 4664181 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S` <br /> THIS PERMIT EXPIRES 1 YEAR FROM <br /> DATE "ISSUED <br /> Date Issued � �� <br /> (Complete in Triplicate) <br /> Appiication is hereby made to the Ban Joaquin Local- Realth District for a permit to. Construct <br /> and/or 'instal, the work herein described. This application is made in compliance with San Joa uir <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sari Joaquin Local-, Health District. <br /> a <br /> JOB.-ADDRESS/LOCATION <br /> CENSUS,TRACT <br /> Owner's Name Lcj <br /> Phone , , - <br /> Address ' / , y <br /> F city <br /> Contractor's Name A An.i <br /> 1141 License # Phone e4 f <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN '/—T RECONDITION <br /> 17 <br /> PUMP INSTALLATION ./ STRUCTION /-7. <br /> /7PUMP REPAIR /�PUMEREPLAC&Mff <br /> Other %/ /�' <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES • PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT r <br /> PROPERTY LINE - PRIVATE DOMESTI _ OTHER <br /> INTENDED USE C WELL PUBLIC DO <br /> TYP OF WELL DOMESTIC WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> /private <br /> Domestic -..._� Cable Tool Dia. of Well Excavation. (^ <br /> --�. <br /> Domestic/public Drilled Dia. of Well Casing <br /> Driven <br /> � � <br /> Irrigation Gauge of. Casing <br /> Gravel Pack � Depth of Grout Seal. � <br /> Cathodic Protection _� Rotary Type of Graut <br /> Disposal Other <br /> Geophysical .. ... �, - Other Information{ <br /> Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> ' -Type ,of Pump AM/ <br /> u �S H.P- <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP '.REPAIR: / /: ':State Work Done <br /> DES;TRUCTION OF WELL: Well.'Diameter F. <br /> Approximate Depth <br /> Describe Material and :Procedure b. ----,- <br /> I hereby agree .to comply with all laws and reg Lti Sof theSan Joaquin ai1 <br /> and the State of California pertaining to orregulating well •'construction>L WithinLl FIFTEENFIFTE�lth trict <br /> after completion of my work on a new well, i �will fYS <br /> urnish the .5an Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the. well and notify tlhem 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 />'RIOR TO GROU N AND A NAL INSPECTION. <br /> SIGNED <br /> TITLE SMS/ ' <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASL� I ! <br /> APPLICATION ACCEPTED BY e• 03 <br /> kDDITIONAL COMMENTS: DATE / <br /> PHASE II GROUT INSPECTION <br /> CNSPECTION BY DATE PHASE III FINAL INSPECTIO L <br /> _ INSPECTION BY DATE $ <br /> E H 1426 <br />