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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 ���/�� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED- - Date IssuedY717 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Focal Health District for a permit-.to construct <br /> and/or install the work herein described. This application is made in compliance with- San Joaquinr <br /> County.Ordinance .No....r1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> 41- ad!Et°e ,e.- is � TRACT <br /> Owner's Name ! OC/ Phone <br /> Address �G�/oo City G- <br /> f - <br /> Contractor's Name o.S j License #2�Phone� �= �'�� <br /> _ � f <br /> TYPE OF WORK (Check) : . NEW WELL / W�EEPEN / / RECONDITION / / DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP RFPLACEMENT_— <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,�p ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> � I <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL c� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing ' <br /> omestic/public Driven Gauge of Casing <br /> 2' Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: ,�[� /-I (,r,rzu'J_ - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <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 pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well., I will furnish the San Joaquin Local. HealthDistrict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well in use.. !, The,_above <br /> information- s,true to -the.-best -of my knowledge and belief. I---WIL-L- CALL -FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F L I SPF TI <br /> SIGNED TITLE _ n <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP TMENT USE ONLY <br /> PHASE I T <br /> APPLICATION ACCEPTED BY DATE I <br /> ADDITIONAL COMMENTS: all <br /> PHASE II GROUT INSPECTION PHASE TTI/FI - INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 11 &41DATE - ` <br /> a <br /> E H <br /> b'/7.7 <br /> 1A26 Rnv 6- . 1_7 <br /> _s,< - 2M <br />