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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATE ISSUED Date Issued l� <br /> (Complete In Triplicate) k� <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. I� <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name ?IPhone I <br /> ' I <br /> Address Q. 0,0 fzl City <br /> Contractor's Name ,Nz" r, 5�o h License Phone <br /> TYPE OF WORK (Check) : NEW WELL 7 DEEPEN '/ / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT <br /> Other / / ._ <br /> DISTANCE TO NEAREST: SEPTIC TANK 11)M SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD """`CES-SPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLt PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of "Well Excavation <br /> Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing cr _....__,.� <br /> Irrigation. Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout-,.. <br /> i <br /> Disposal Other Other Information _ <br /> Geophysical Surface Seal Installed By: �. •�, to ', <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump tA � * .��..� ;�€" H.P. J T <br /> I <br />?UMP REPLACEMENT: / / State Work Done <br />?UMP .REPAIR: � I <br /> State Work Done <br /> i <br /> i <br />)E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> JELL DRILLERS REPORT of the well and notify them before putting the well- in use. The above <br />_nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION- <br /> RIOR TO GROUTING AND_A FINAL INSPECTION. <br /> iTGNEDy"i a o-,_4..k TITLE AA <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - �T <br /> FOR DEPARTMENT USE ONLY <br />'RASE I <br />►PPLICATION ACCEPTED BY DATE 0 <br /> JDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC ON PHASE TIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE r J <br /> E H 1426 4Rpv_ 1-7A 1177 .. • 2M <br />