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c _ <br /> �a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 2 Telephone: (209) 466-678i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7e,'- 333/1 <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 fog 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 /> .TOB ADDRESS/LOCATION� �.� GcJ: �,� j/,/lc o� CENSUS TRACT <br /> Owner's Name ti Phone '3 <br /> Address 3 Cit <br /> Contractor's Name _./�D . License Phone <br /> Phone;33 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /? RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR-/_7 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 f Cable Tool, Dia. of Well Excavation <br /> f Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public r 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 .& <br /> Type�of Pump 1 H.P. <br /> 3 _ <br /> s <br /> PUMP REPLACEMENT: • A State Work Donep,,K of=d Aon 22:=�j <br /> PUMP .REPAIR /% `'State Work Done <br /> DE&TRUCTIO_N OF WELL: Well Diameter - = n 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--notifyxthem-before-putting-the.'.well-'iii.tise...'.The above <br /> information is/true to the-best -of my..knwwl, dge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU G A FIN SPECTION. <br /> SIGNED TITLE <br />` 2MDRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �9DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE Z jit tV <br /> as _re/ .�►• ��' i <br />