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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. ���7�d <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _46IIE Zf!XX . C,�ore#= CENSUS TRACT <br /> Owner's Name Lin _ Phone <br /> Address tt <br /> Ewle Aeoor. City <br /> Contractor's Name - License # xnPhone <br /> r � - <br /> a <br /> TYPE OF WORK (Check) : NEW WELL /K DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER YNESj� PIT PRIVY - <br /> SEWAGE DISPOSAL MELD/:- CESSPOOL/SEEP�GE PIT OTHER <br /> PROPERTY LIN, dPRIVATE DOMESTIC WELD PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �.. <br /> Industrial Cable Tool Dia. of Well Excavation d <br /> Domestic/private Drilled Dia. of Well Casing !, (A <br /> Domestic/public Driven Gauge of Casing ,3'1Ap� <br /> r Irrigation Gravel Pack Depth of Grout Seal _a �f <br /> Cathodic Protection _ Rotary Type of Grout _ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed_ By: / C _#C1�iJ <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 Approximate Depth <br /> Describe Material and Procedure <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 AND A FINAL INSPECTION. <br /> SIGNED ✓ ,r. TITLE <br /> (b'RAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE 4 GROUT INSPECTION P E TII/FIN4 INSPECTION <br /> INSPECTION BY ZA DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 / / 2M <br />