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q r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "F—OF-­OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / f <br /> THIS PERMIT EXPIRES l 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 Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Tr <br /> CENSUS TRACT <br /> e� !moi GAS - <br /> Owner's Name Phone Q,r <br /> Address r (L -- �,�,� �J CityC9 �i� <br /> Contractor's Name , License 6Phone /toy -061k <br /> F <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION / / DESTRUCTION 14 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f / <br /> Other / / - - <br /> DISTANCE TO NEAREST: SEPTIC TANK jj• SEWER LINES 1 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER + <br /> PROPERTY LIN%a `PRIVATE DOMESTIC WELL .!t-WPUBLIC 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 <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump H.P. i <br /> _ r <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'constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i WELL DRILLERS REPORT of the well and notify them before putting thewell 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 NSPE TION. T <br /> SIGNED TITLE <br /> (DRAW P OT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B �] DATE �l�j '7 <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION HASE_IWIFINA INSPECTION <br /> INSPECTION BY DATE INSPECTION DATE y <br /> E )177 _ 2M <br /> F H '1626 RP[T_ . 1-7L A/ <br />