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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FO FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> P: Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TV- 3S Z-d <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 herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION 2—JO 7-3 4 CENSUS TRACT <br /> Owner's Name 0 Phone?,f <br /> Address p• City <br /> Contractor's Name * !ice License #/1?M1&Phone <br /> -TYPE OF WORK (Check).- NEW --. �.-��-- <br /> WELL �� DEEPEN/! RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other / { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 11- ILM <br /> Domestic/private Drilled Dia. of 'Well Casing <br /> Dotaestic/public Driven Gauge of Casing / <br /> Irrigation Gravel Pack , Depth of Grout Seal --7-- <br /> Cathodic <br /> 7Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> k Type of PiMp H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: /�—.StatezWork-Done. <br /> PE5'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> F Describe Material and Procedure <br /> I <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 Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the .well in-use.. The above <br /> 4 informatio is true t the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> i PRIOR Tovt UTING FINAL INSF ION.- <br /> SIGNED <br /> ON.SIGNED '"" TITLE ��N���e� � <br /> (DRAW-PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY IiMA _ DATE 7`o'�` <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION 3> , ���.` INSPECTION $yHASE III/F AL DATE/INSPECTION BYDATE � <br /> F <br /> 51 E H 1426 Rev. .I-74 <br />