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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. 3G <br /> THIS• PERMIT EXPIRES l YEAR FROM DATE- ISSUED Date Issued- <br /> (Complete <br /> ssued(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". oCi CORMCR [d F � �.' ddUer' ' . �G<,�'� CENSUS TRACT <br />€ Owner,'s Name /, 411771 „ Phone <br /> Address cityQ,� I <br /> Contra ctor'..s Name. . License #3zd.37,8Phone 36 ; 71 <br />` TYPE OF WORK -(Check) ; NEW :WELL %/ DEEPEN / /A .R2CONDITION` /�/ :DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /+ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC :TANK SEWER LINES PIT 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 i Drilled Dia, of .-Well Casing . <br /> Domestic/public i.. Driven Gauge of Casing <br /> Irrigation- ; Gravel Pack Depth of Grout Seal. <br /> Cathodic, Protection i Rotary ., Type of Grout <br /> Disposals ' .i i Other Other Information <br /> Geophysical' --- - <br /> "` Surface Seal7Irfstalled E <br /> 1A <br /> PUMP INSTALLATION: .Contractor � . <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: / / State Work_ Done ' <br /> PUMP .REPAIR: /«State Work DoneY �' �G C� <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 knowledgeFandbelief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING-AND A FINAL' INSPECT N. <br /> SIGNED ! t TITLE <br /> W PLOT PLAN ON REVERSE .SIDE)(Division of San Joaquinulp ur of <br /> FOR DEPARTMENT USE ONLY acrarnen o St. <br /> PHASE I Lodi, Califernia 95240 <br /> APPLICATION ACCEPTED BY / DATE 2 <br /> ADDITIONAL COMMENTS: J . } / , <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 POW 1-7A 2M <br />