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4 <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> COQ OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No�2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _/ 27 <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 is made in compliance with San Joaquin] <br /> County Ordinance No. 1862 and the Rules and Regulations of t e San Joaquin Local Health District. i <br /> r i <br /> JOB ADDRESS/LOCATION rJ 5C7 ' ` CENSUS TRACT M <br /> Owner's Name4ta=iJ2- 62��� Phone <br /> Address City <br /> Contractor's Name .� <br /> License Phone <br /> S - <br /> . t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN%/ RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INST ,ATION / J PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC, TANK SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL`'FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE%-- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE.--OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> t_-Domestic/private _ 4 drilled Dia. of Well Casing <br /> Domestic/public J <br /> /p � _:� Driven Gauge of Casing <br /> Irrigation "` Gravel Pack Depth oGrout Seal <br /> Cathodic Protection ��4_Rotary Type of ou Q <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:_ _ <br /> PUMP INSTALLATION: Contractor <br /> Type, of Pump H.P. <br />,PUMP REPLACEMENT: /, / State Work Done � <br /> } <br /> PUMP 'REPAIR: State Work Done <br /> r <br /> ES-TRUCTION-OF-WELL We11_'D ameter -c�cr i¢� Approximate Depth <br /> Zescr.'be- Materi 1, and Procedure <br /> I hereby agree to compy with all laws and regulations of the S n Joaquin Lo Health District <br /> and the State of California p -rt�a ning�to.o.r„ r,.eg-u aat ,ng,�.we1:1-,;;constrn uction..—W: thiFIFTEEN DAYS <br /> 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 I <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G OUTING A FINAL INSPECTION. ' <br /> SIGNED TITLE _ <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR ADEPARTMENT USE ONLY " '�• <br /> PHASE I ; <br /> APPLICATION ACCEPTED BY DATE 3 T <br /> ADDITIONAL COMMENTS: <br /> PHASE GROU INSPECTION PHAU III/FINAL INSPECTIO , <br /> INSPECTION BY / ATE INSPECTION BY DATE <br />