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SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> Telephone : (209) 466-6781 - <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> r <br /> THIS!PERMIT EXPIRES l 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 Jo4quin { <br /> County Ordinance No. 186q22da the Rules and Regulations o the San Joaquin Local Health District.0 (Z F <br /> JOB ADDRESS/LOCATION I <br /> CENSUS TRACT } <br /> Qwner's Name .� Phon;Q ��'4 <br /> Address City <br /> lontractor's Name License one- <br /> I` <br /> a <br /> CYPE OF WORK (Check) ; NEW WELL DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_ <br /> ALL <br /> PUMP INSTATION PUMP' REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br />)ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES VZ— PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WE��_L-_� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL `CONSTRUCTION. SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /r <br /> Domestic/private Drilled —Dka: bf Wefi Casing:, ! G <br /> Domestic/public Driven s Gauge of `Casing <br /> Irrigation Gravel Pack Depth of Grout Se <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br />'UMP INSTALLATION: Contractor , <br /> Type of Pump .�' H.P. <br />'UMP REPLACEMENT: + <br /> State Work Done " <br />'UMP •.REPAIR: / / State Work Done R <br /> ESTRUCTION OF WELL: Well Diameter_ Approximat Depth eo <br /> eAsle 'Maf Tial androcedu`r:ehereby agree to coC_D <br /> y ll .laws andreeguulations of the San Joaquin Local Health Dis ict <br /> nd the State of Californi'e�e"rtaining to or regulating well construction. .,Within--FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the Sanw•Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well, and notify them before-putting the- well in.use.. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO C14UTING AV9A FINAL 92PECTION. or <br /> IGNED r , TITLE !'I <br /> (DRAW PLOT.PLAN ON REVERSE SI7 7D j <br /> GOR DEPARTMENT USE ONLY <br /> HASE <br /> PPLICATION ACCEPTED BY ` a '-` .d � s� Y A DATE7— L `7 7 <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE I 1131,,77RNSPECTION BY DATEE�//- <br /> E H 1'426 Rev. 117 v i � �/ '/, ��yae C D/✓ �f'A7" �% 7 � � <br />