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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1. Telephone: (209) 4666781 <br /> :21 0112 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued lS <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 e Rules- and Regulations of the San Joaquin Local Health District. <br /> a �r1 ! W�S 14410,;�• S1Frr, d <br /> JOB ADDRESS/LOCATION �-e CENSUS TRACT <br /> Owner's Name Phone F 2 ? — � k <br /> Address City lo <br /> Contractor's Name License Phone G % <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION j / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP--REPAIR / / PUMP REPLACEMENT /-7 1-b <br /> Other / / N- <br /> DISTANCE TO NEAREST: SEPTIC TANK�6�C,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 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: Cx.,j A ) jn, <br /> PUMP INSTALLATION: Contractor ,,-�7"" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 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 /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FIN --I SPECTION. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IIAGROUT INSPECTION PHASE III/FINAL INSPEGTIO <br /> INSPECTION BY DATE�ar �' INSPECTION BY DATE f <br /> 160 ' < �+ao.�al/3 s '. �ic?%� � <br /> ori%7 _ <br />