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10 VIIIII`t�- <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> FOP, <br /> U5E: 3601 E. Hazelton Ave. , Stockton, Calif. i <br /> OFFI — Telephone: (209) 466-67$3 <br /> FOF <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> u <br /> (Complete Ca In Triplicate) <br /> ct for a permit( mp P <br /> Application is her sande to the San Joaquin LoapplicationalHealth istmade in compliancetwith San .�oaquin <br /> and/or install the work.; herein described. This <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> �JZ CENSUS TRACT <br /> JOB ADDRESS/LOCATION S ^►/ <br /> Phone <br /> Owner's Name <br /> :I: r City <br /> -Address . <br /> I <br /> License o. 4S Phone <br /> Contractor's Name F -/p <br /> ��NEW WELL DEEPEN '-/ RECONDITION"`I� DESTRUCTION f T fn <br /> TYPE OF WORK (Check): <br /> 11 PUMP INSTALLATION /�`,IPUMP REPAIR / PUMP REPLACEMENT I T <br /> Other <br /> DISTANCE TO NEAREST: SETANK �_ SEWER LINES PIT PRIVY <br /> PTIC. 1 <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 d't <br /> Domestic/private Z4 Drilled Dia. of Well CasingF <br /> Domestic/public ; Driven Gauge of Casing \ <br /> i Irrigation ! Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout < <br /> Disposal ; _ y '- Other _ Other Information <br /> Geophysical_ '_ Surface Seal Installed BY: <br /> 1101 <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPI`ACEMENT: %/ State Work Done <br /> f /-7 State Work Done <br /> PUMP !REPAI�t: �� <br /> ES;TRUCTION OF WELL: it Well Diameter A pproximate Depth <br /> f� <br /> Describe Material and Procedure ! <br /> I Hereby agree to comply with all laws and fegalations 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 DR RS REPORT 'of the well and noti€y them before putting• the..well in.use.. The above <br /> info anon s true t t e beat uiy knowledge and 1�elief. I WILL CALL FOR'A 'GROUT INSPECT <br /> PRIOR TO GRO TING AN CT ION.' <br /> SIGNED I TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEP HENT USE ONLY <br /> PRASE I ; DATE <br /> APPLICATION ACCEPTED BY --`-�-'� <br /> ADDITIONAL COMMENTS: . + <br /> PHA I GR TINS CT . N PHASE III F IN ECTION <br /> _ INSPECTION- BY D E <br /> INSPECTION BYE <br /> (�S e R � 1-7 4 2M <br /> E H 142 <br />