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r <br />` SAN J A,QUIN LOCAL HEALTH DISTRICTA -- <br /> FOR OFFICE-------------------- <br /> SE: 1601 E. LHazelton Ave. , -,..Stockton, `Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75 .2-3024) <br />��� � THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Aoplication 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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3 e <br /> CENSUS TRACT <br /> Owner's Name <br /> f <br /> 4 Phone <br /> Address <br /> City <br /> Contractor's Name . <br /> Licende// e7%�_ <br /> yPogm Phon /-a <br /> TYPE OF WORK (Check): NEW WELL /�� p -T/"7~ RECONDITION /7- DESTRUCTION <br /> PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT- /f <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �N <br /> SEWAGE DISPOSAL FIELD CES$ OP OL/SEEPAGE PIT <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF W L CONSTRUCTION SPECIFICATIONS <br /> Industrial le Tool Dia. of Well Excavation . <br /> CD-o-mestic/private Drilled Dia. of Well Casing <br /> Domestic/public �.�_ Driven Gauge of Casin <br /> Irrigation g <br /> Gravel Pack Depth of Grout Sea <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ` <br /> Geophysical _ _ � Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump <br /> H.P. } <br /> PUMP REPLACEMENT: / / State Work Done 1 <br /> Sta- ork Dane <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> TIOR TOG UTI YNAL INSP ION. <br /> SIGNED ' <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />?RASE I FOR DEPARTMENT USE ONLY <br /> 4PP� L TION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PRASE II FINAL INSPECTION <br /> INSPECTION BY DATE - <br /> INSPECTION BY DATE <br />