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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 466-6781 VW <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N021 r <br /> je. THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedf-� <br /> (Complete. In Triplicate) i <br /> Ap on is hereby made to the San Joaquin Local Health District fora 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 /> JOB ADDRESS/LOCATION' CENSUS TRACT ' <br /> Owner's Name `/��G/ ece Phone <br /> Address City -4.r-It <br /> Contractor's Name License # �Phone <br /> TYPE OF ,WORK (Check) : NEW WELL / / DEEPEN / ,/ RECONDITION /_/ DESTRUCTION /� _ <br /> PUMP INSTALLATION / / PUMP REPAIR /' / PUMP REPLACEMENT <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 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public P Driven Gauge of Casing- <br /> 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. .5 _ <br /> PUMP REPLACEMENT: /" ] State Work Done <br /> PUMP REPAIR: /x/ 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 workon a new well, I will furnish the San Joaquin Local Health District a , <br />` WELL DRILLERS REPORT of the well and notify them before puttingthewell in use... The above <br /> information is true to the best of my knowledge a elief. I WILL CALL FOR A GROUT INSPECTION_ <br /> PRIOR TO GROU ING AND A FINAL, INSPECT 0 <br /> SIGNED - ITLE ✓�j' ' _ -- -- <br /> (D T T P AN ON RE RSE SIDE) <br /> OR -DEPAR MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ^- 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N' PHAS INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY &aATE <br /> C l <br />