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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1 OFFICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> f 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 2/�G/ 7d" <br /> (Complete In <br /> Application is hereby made to the San Joaquin Local Triplicate) <br /> Application <br /> a permit <br /> and/or install the work herein described. This application alth Distmade inrict rcompl ancetwithnct SanuJoaquin <br /> County Ordinance No. 1862 and ,th.e Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ©, � (j+ / . <br /> 1 - <br /> CENSUS TRACT <br /> Owner's Name '06// r - <br /> Phone <br /> Address <br /> City <br /> Contractor's Name C,_ License 43_361>S_5_Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEP N f / RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR /__ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN G' SEWER LINES PIT PRIVY ., <br /> SEWAGE DISPOSAL FIELD <br /> ° CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTX LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION <br /> ATIONS c. <br /> SPECIFIC <br /> Industrial <br /> Cable Tool Dia, of Well Excavatign/ <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal I <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical .Surface Seal Installed _Ay.: . <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump cl <br /> - <br /> PUMP REPLACEMENT: State / � <br /> State Work Done � <br /> PUMP .REPAIR: / / State Work. Done <br /> IES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure — Approximate Depth <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 /> BELL 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 />'RIOR T ROUTING n F INSPECTION. <br /> iIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTME <br />'RASE I NT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> LDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E II NAL INSPECTION T <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H-1426 uA., . 1_7A <br />