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/' SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> i 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 3-7 <br /> s <br /> (Complete In Triplicate) <br /> Application is hereby made the Sart Joaquin Local Health District for a permit to construct ; <br /> and/or install the work herein described. This application is made in compliances with San Joaquin; <br /> County Ordinance No. 1862 and the-Rules ?,� NtiQxof the San -Joaquin Local Health District. <br /> 1��y� � �'cENSus TRACT <br /> JOB ADDRESS/LOCATION '. L�5. ee x <br /> Phone <br /> Owner's Name ' Qe °� <br /> - City � /j'�a w ��.CL <br /> Address °t <br /> � S `i�' <br /> Contractor's Name A)4 S Names � A� a�� �� , License # ( L Phone �^+�3 YSk <br /> k TYPE OF WORK (Check): NEW WELL/� DEEPEN '/7 RECONDITION /? DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT /_7 <br /> Other <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> DI <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER U <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 Dia. of Well Casing �^ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ' s O <br /> Disposal Other Other Information <br /> I _Geophysical t <br /> Geo h sical Surface Seal Installed By: <br /> _ . . � - � <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump �-r,..r A) +S H.P. s- <br /> PUMP REPLACEMENT: . . / /F State Work Done <br /> PUMP '.REPAIR: / /` State Work Done <br /> DESTRUCTION OF WELL: Well2 Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> F <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, 1-will furnish the San Joaquin Local Health District + <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 AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FDR DEPARTMENT USE ONLY <br /> PHASE I k DATE -I ' <br /> APPLICATION' ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE IINAL SPECTION <br /> PHASE I GROUT INSPECTION TP <br /> INSPECTION BY - DATE INSPECTION BY <br /> 2M <br />