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eom SAN JOAQUIN: LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone : (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S�U <br /> THIS, PERMIT EXPIRES I YEAR FROM .DATE ISSUED Date Issued 'Z/�/-)] <br /> t� (Complete .In Triplicate) t7cf -62� -f <br /> Application is hereby made tolthe 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 .Vealth District. <br /> JOB ADDRESS/LOCATION / ��CaS� s( � CENSUS TRACT <br /> Owner's Name .St &t o T oil Phone <br /> Address i , f City d 4 <br /> Contractor's Name r 1� License # 1 7l. ''phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION — <br /> PUMP REPAIR'- // PUMP REPLACEMENT /_7AL <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 1 Cable Tool Dia, of Well Excavation <br /> Domestic/private E Drilled Dia: of Well Casing <br /> Domestic/public .i Driven Gauge' of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Il Rotary Type of Grout <br /> Disposal A Other Other Information , <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Pump H.P. <br /> Type of - <br /> � 1 <br /> II PUMP REPLACEMENT: / V State Work Done <br /> PUMP REPAIR: State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby agree to comply1with 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 <br /> t WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the bes_Lof my e and belief, I WILL CALL FOR A GROUT INSPECTION ��� <br /> PRIOR TO GROUTING AND A F E I N. <br /> SIGNED TITLE P/- <br /> j/zz {DRAW PLOT PLANav-ERSE SIDE) <br /> FOR DEPARTMENT 'USE ONLY <br /> PHASE I <br /> r APPLICATION ACCEPTED BY DATE _ _ <br /> ` ADDITIONAL COMMENTS: <br /> PHASE II . T ; NSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY -DATE INSPECTION BY DATE /! ' "� <br /> 2M. <br /> }i. T� 7LL7fl RP\7- �-7LL <br />