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SAN JOAQUIN LOCK—HEALTH DISTRICT <br /> a FOBfflFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:P (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Isse:ed 3-02 - cG <br /> (Complete In Triplicate) G-� <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.i-1862 and the Rules and Regula ons of the an Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION. <br /> f <br /> CENSUS TRACT <br /> Owner's Name , a <br /> Phone <br /> Address' <br /> City <br /> Contractor's Name Z4 <br /> License # Phone � <br /> 2(4 _,3M0 <br /> TYPE OF WORK (Check): NEW WELLe' DEEPEN -/? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION _/ / PUMP REPAIR a <br /> Other /_7 <br /> /� PUMP REPLACEMENT /? <br /> DISTANCE TO NEAREST: SEPTIC TANKi <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESS OP OL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL . <br /> INTENDED USE TYPE OF WELL CPUBLIC DOMESTIC WELL NQ <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation /f 3 <br /> Domestic/private Drilled Dia. of Well Casing << <br /> Domestic/public <br /> Driven Gauge of Casing a, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary <br /> Disposal Type o£ Grout c ✓03121 <br /> Other Other Information <br /> Geophysical r -'�'--•~-- <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: /-7 State Work Done <br /> ESTRUCT� ION OF WLrI,L: Well Diameter <br /> Approximate Depth , <br /> Describe Material and Procedure <br /> J hereby agree to comply with all laws and regulations of the San, Joaquin Local Heal <br /> and the State of California pertaining to or regulating well construction. Within F'IFTEENtDAYS <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 FbR A GROUT INS <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. PECTION <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATEI _�![a5 '?� <br /> PHASE Ii GROUT INSPECTIONi <br /> INSPECTION BY 1 PHASE III/RINAL INSPECTION <br /> DATE '� INSPECTION BY DATE <br />_'','E H 1426 'Rev. I-74 - <br />