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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION `? r7_..ort a,.;.t., U1A, T c nc i[, . CENSUS TRACT _ <br /> ''.. GR .� <br /> 1 u' <br /> Owner's Name 4 C. � l r r 4 C? <br /> Phone <br /> Address " � ;rn -_ <br /> City #,,r�',:ton <br /> Contractor's Name ' <i'l 11"'S, <br /> .' <br /> Co License �� ° Phone 85 <br /> License <br /> TYPE OF WORK (Check) : NEW WELL /N_/ DEEPEN / / RECONDITION /w/ DESTRUCTION /-7 �.- <br /> PUMP INSTALLATION / / PUMP REPAIR /--/' PUMP REPLACEMENT <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SEWER LINES _ POPITY PRIVY _ —^ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMEST — <br /> INTENDED USE TYPE OF WLLL IC WELL <br /> InCONSTRUCTION SPECIFICATIONS <br /> Industrial CONSTRUCTION Tool Dia, of We 1.1 a <br /> Excavtion <br /> Domestic/private Drilled <br /> Dia. of Well Casing4r— <br /> Domestic/public Driven Gauge of Casing _ ................. <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Cathodic Protection Rotary Type of Grout f-% CX ''I X <br /> Disposal —"— <br /> Other Other Information <br /> Ge.o.phYsa cal `' Surface Seal InstalledµBy <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 G <br /> PRIOR TO' GROUTING AND A FINAL INS PI CTION ROUT INSPECINSPECTION <br /> SIGNED . , _ <br /> TITLE f , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -- 1 <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 140110 <br /> ADDITIONAL COMMENTS: DATE S /� 711c- <br /> PHASE II GROUT INSPECTION ' <br /> INSPECTION BYPHASE III/FINAL SPECTION <br /> DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 n/%7 2M <br />