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SAN JOA UIN LOCAL HEALTH DISTRICT ' <br /> FOR,OFFTAg USE:A 1601 E. Hazelton Ave. , Y2,)7/Stockton, Calif. "�� <br /> Telephone: (209) 466-6781 7;7-" pQ[J <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> t (Complete In Triplicate) <br /> Application is Aereby 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 Joaqu Local Health Dist#ct. <br /> JOB ADDRESS/LOCATION p ,p <br /> � AO So, f� fF�-kyr ZZ), 'S,c�� ,Q� ,<?A., ENSUS TRACT <br /> di kc4 nKkN,N ^/, "'d S. <br /> Owner's Name , Phone <br /> Address City <br /> Contractor's Name1061 License #/a _ Phone <br /> TYPE OF WORK (Check) : NEW WELL /,( DEEPEN/ % RECONDITION /7 DESTRUCTION /7 <br /> PUMP INST"AL'tLATION / / PUMP REPAIR / / 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 <br /> Domestic/Private _ _ _Drilled- -:_, Die. o€-Well-Zasfng -- <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack . Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout0611 gir <br /> ' s <br /> Disposal ,Other Other Information <br /> Geophysical Surface Seal Installed BY: A/-,,S <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 WE": Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of theSan Joaquin Local -Healthis <br /> Dtrict <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 shove <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GP4UTWGANJQFINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATEA , <br /> ADDITIONAL COMMENTS: <br /> PHASE ' I GROUT INSPECTION P III AL NSPECTIO <br /> INSPECTION BY T DATE INSPECTION B DATE <br />