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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466•-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zy r�J <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 Joaquin <br /> County Ordinance No. 186 and the Ruleq and ulat n of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAfiIaAA VAbi ALL.�qCENSUS TRACT <br /> Owner's Name i' '�`LA.S Phone 3�tra <br /> Address A16-0-9- 5 C LL-10 It f y ► <br /> Cit , P6-hl <br /> Contractor's Name �� <br /> hi License # 116&1 Phone ,JE4 <br /> TYPE OFWORK (Check): NEW WELL <br /> / DEEPEN_/_7 RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTAL ATION / / PUMP REPAIR '/_7 PUMP REPLACEIENT /f <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private . Drilled _ <br /> c �'-- --- Dia.�o€.-Well <br /> /pu"blic Driven .Gauge of Casing <br /> Domesti ( <br /> Irrigation 9/2!!i N/lek; Gravel Peck Depth of Grout Seal <br /> Cathodic Protection . Rotary Typeof Grout . <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B i <br /> t 5 i� <br /> I <br /> PUMP INSTALLATION: - " R <br /> -.Contractor ., .. _ - , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. / / State Work Done *, <br /> PUMP:!REPAIR:--- - /71---State -Wojrk Done <br /> DES.TRUCTTON OF WELL: Well Diameter f Approximate Depth <br /> Describe Material and Procedure <br /> k <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 /> PRIOR TO GROUTING ANDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS; DATES <br /> PHASE II GROUT INSPECTION PHA III INALINSPECTIO <br /> INSPECTION By DATE „ INSPECTION BY DATE Z <br /> E H 1426 uav_ 7_7G + __ <br />