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L <br /> 1 Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE ,USE: 1601 E. Hazelton Ave. , Stockton, Calif. F ; <br /> Telephone: (209) 466-6781. iy,' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � � k <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE' ISSUED Date Issued �{���'� <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 here�n described. This application is made in compliance with San Joaquin <br /> County Ordinance 'No. 186-2 and -the-Rules and Regulations of the San Joaquin Local Health District. <br /> 2ti S `r 715�� `C',74067 ifs <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name yVS' idL - ---- - - Phoneg `� ' <br /> Address cityr <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL' /Z71' DEEPEN /_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST:. SEPTIC TANK aa"` SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 0- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINIZiO�PRIVATE DOMESTIC WELLS " PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation 2e ,, ! <br /> Domestic/private Drilled Dia. of Well Casing -- <br /> Domestic/public Driven Gauge of Casing <br /> X 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: <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 /> e <br /> and the State of California pertaining to or regulating well '-cons.tru'ction. ` Within FIFTEEN DAYS � <br /> after completion of my work on a new well, I will furnish,the.Saii 7oaq:ui:n ,Local` Health District a <br /> WELL DRILLERS REPORT of the well and notify them before pu'. ng 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 /> PRIOR TO GROUTING AND A FINk4 INSVECTION. - <br /> n;? <br /> SIGNED TITLE ��.. �: + ►�!/� — — <br /> 17 DRAW PLOT PLAN ON REVERSE SIDE' <br /> FOR DEPARTMENT USE ONLY,,- <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE. III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE *7-" a� <br />