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,�•' SAN JOAQUIN LOCAL HEALTH DISTRICT G <br /> FOF OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. h <br /> i. <br /> Telephone: (209) 466-6781. ��` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM ]TATE ISSUER' Date Issued <br /> ',2©`fQ°:7:• r1: �. r� .02�: t: (Complete In Triplicate) 7+70P-.) 0113 0&nInr0�G 3 <br /> Application is hereby made to the San Joaquin Local Health District for a 'permit to constituct � <br /> and/or install the work herein described. This application is made in compliarice. with San Joaquin; <br /> Count Ordinance No. 1802 andth Ru s . nd R ul s the San -J aquin Local Health District. <br /> JOS ADDRESS/LOCATION C 6 CENSUS TRACT ' ; <br /> t <br /> Owner's Name Phone <br /> Address �� _. 'A �� 'A City <br /> .Contractor s. Name }�i License C� honer/_, <br /> ij <br /> TYPE OF WORK. (Check).:. NEW WELL /_t�DEEPEN / / RECONDITION / /.: -,DESTRUCTION -7 - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / J i <br /> DISTANCE TO NEAREST: SEPTIC TANK C> EWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PR6PERTY LINE -.PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL n <br /> INTENDER USE TYPE ,OF WELL CONSTRUCTION SPECIFICATIONS J <br /> Industrial Fable :Tool Dia.' of Well Excavation <br /> •. . <br /> _IDomestic/private Drilled r.­—Dia.' of Well Casing <br /> -"Domestic/public Driven ` Gauge of Casing f e <br /> 1 - irrigation Gravel Pack ' Depth of`Grout Seal <br /> Cathodic Protection Rotary Type. of-Grout l' <br /> Disposal Other Other I.nformati.oA'_- <br /> Geophysical Surface4S-eal—Ins-talled -By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump y' H.P, <br /> E PUMP REPLACEMENT: / / State Work Done n <br /> PUMP REPAIR:_ / StateWorkDone _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> I hereby agree to comply with all laws and regulations sof the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> j after completion of my work on a new 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 /> infarm'ation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND A FINAL INSPECT;0,;q? <br /> SIGNED ' TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> •.� - � ' {, ' y ..; FOR DEPARTMENT- USE ONLY <br /> t"PHASE'i <br /> ;'APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ FIN INSPECTION �. : <br /> INSPECTION BY DATE INSPECTION BY DATE --/ • <br /> . 0/7.7 2M <br /> c u 11.9A 1D , " l_7G <br />