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Co SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> FOE;OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> y' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,6- ;, y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -9t <br /> (Complete ,In Triplicate) ! <br /> Application is Hereby spade to the San Joaquin Local Health District for a permit .to .construct i <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 .�t � � .-�-`�, CENSUS'TRACT <br /> Owner's NameAlln ,v- e, Phone <br /> Qr� <br /> Address � �� J ^4 <br /> � �'3-� City- <br /> Contractor!.s Name License # -?hone ' c 29 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/? RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION-&/ rPUMP"REPAIR / PUMP REPLACEMENT /? <br /> Other j/7 <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL: PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> >_ Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public DrivenGauge of Casings , <br /> Irrigation Gravel Pack _ Depth of Grout Seal'* <br /> l <br /> _._ <br /> Cathodic Protection Rotary --Type' of-trout <br /> Disposal Other Other Information <br /> Geophysical . <br /> Surface Seal Installed By: <br /> PUMPINSTALLATIONo Contractor , ,.. ' <br /> Type of Pump i p�-� - H.P. <br /> PUMP REPLACEMENT: / State Work Done`; <br /> r Lam✓ . <br /> PUMP REPAIR: State Work Done, <br /> DESjRUCTfON bF ,WELL:'_ Well. Diameter w" `~s -- - - APP.roX irate 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''constructi.on.. 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 df,-':the well .and notify them before putting.-the -well in.use.... .The above <br /> information is true to the•best.of my knowled a and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANDA FINAL INSPECTIO <br /> SIGNED t7e r ITLE <br /> / <br /> (DRAW PIVOT PLAN ONRWRSE SIDE) i <br /> R <br /> DEPARTMENT USE ONLY <br /> ,PHASE I <br /> APPLICATION ACCEP BY DE - :DATE -�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE , i I/71NAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426- 1.cz qu..a, .a } <br />