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._.,. . <br /> G SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Foie;,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2�d_ X3 <br /> A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7G <br /> (Complete In Triplicate) <br /> Application io-here-by made t, the San Joaquin Local Health District for a permit to Construct <br /> and/or install the .work herein described. This appl.ication.is made in compliance with San Joaquin <br /> County Na17 .. 1862 and, the Rules and Regulations of the San Joaquin Local Health District. - <br /> * a ,. I � <br /> JOB ADDRESS/LOCATION W CENSUS TRACT <br /> S�C .7G 1 <br /> Phone <br /> Owner's Name �;' <br /> I_ L City ` <br /> Address - •• <br /> Contractor's Name License Phone 'A <br /> TYPE OF WORK (Check): NEW WELL y DEEPEN '/-7 RECONDITION f7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR'/ PUMP REPLACEMENT I=T <br /> J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES PIT PRIVY _ <br /> - SEWAGEkDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation , ` <br /> Domestic/private _ Drilled Dia. of Well Casing 2 <br /> DdmesticJpublic i Driven Gauge of Casing <br /> lirigation it- Gravel Pack Depth of Grout Seal <br /> Cathodic Protection j Rotary Type of Grout ' <br /> ' Disposal' , i Other Other ..Information <br /> Geophysical- .Surface Seal Installed 'Byf <br /> PUMP INSTALLATION: Contractor <br /> Typelof Pump _ H.P. <br /> ! PUMP REPLACEMENT: , / .State Work Done <br /> ' PUMP (.REPAIR: / / .State Work Done ; <br /> 4 <br /> 'DES+TRUCTION OF WELL: .Well Diameter Approximate Depth <br /> Describe Material and,Procedure, <br /> [ I hereby agree to comply with all Maws and regulations of the Sar .Taaquin Local Health District <br /> and the State of Calif ornia .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 ywell 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 /> PRIOR TO GR TING'AN FINAL INSPECTION. <br /> SIGNED - ' TITLE <br /> . (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE �� <br /> •'.Z 7' <br /> (ADDITIONAL COMMENTS: . � <br /> PHASE II GROUT INSPECTION` PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 2M <br /> r u ILIA Qtr ^1f_7A r' <br />