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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O .OICE USE: t 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone., . (209) 466-6781 <br /> APPLICATION FOR IWELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS. PERMIT EXPIRES 1, YEAR 1"ROM DATE ISSUED Bate Issued /j_Z7 <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 the Rules and ati sof: the San Joaquin. Local Health. District. <br /> JOS ADDRESS/LOCATION.. F () ' G? CENSUS TRACT <br /> Owner's Name <br /> Phone 2`L `I L �C <br /> 60-a, <br /> City <br /> Address <br /> Contractor's Name License #4-N-910 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION % <br /> r PUMP;.-INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Ir / <br /> Other / ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES., PIT-PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> E. INTENDED USE .,TYPE OF WELL :s'' CONSTRUCTION SPECIFICATIONS '\ <br /> u; Industrial I Cable Tool Dia', of Well Excavation R- <br /> ` Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public _ Dr.iven ,Gauge_of _Casing f <br /> Irri gatiori` Gravel Pack D th of Grout Seal <br /> k Cathodic Protection Rotary , TYpe of Grout <br /> F <br /> Disposal Other ; Other Information <br /> Geophysical _ & Su face Seal Installed By: <br /> t <br /> ' PUMP INSTALLATION: Cont ctor <br /> Type of Pump H.P. f <br /> r PUMP REPLACEMENT: State Work Done /���j �� / 12e& <br /> f <br /> PUMP .REPAIR: / / � State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procure <br /> i <br /> I hereby agree to comply with all laws and regu ations 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 i <br /> I WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> [ PRIOR TO G UT NG AND A F AL INS, ECTIO <br /> k SIGNED TITLE4ag&� <br /> k € - (DRAIJ PLOT PLAN ON REVERSE SIDE <br /> PHASEI �� FOR DEPARTMENT USE ONLY <br /> ' _ <br /> APPLICATION ACCEPTED BY0 DATE <br /> i ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSKCTION ;. ' . PHASE`-IffI/FIN INSPECTION <br /> sINSPECTION BY ! DATE IN PECT `ON BY E3ATE J '� <br /> f�GAN�'�`• ' <br />