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t I , <br /> IT SAN JOAQUIN LOCAL. HEALTH DISTRICT c , <br /> F'OF`,OFFICE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 4•66--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> V <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> ] <br /> ! (Complete In Triplicate) <br /> Application is tereby 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 Dist pct. <br /> JOB ADDRESS/LOCATION <br /> CENSUS. TRACT � <br /> Owner's Name <br /> Phone 2 ` <br /> Address City <br /> Contractor's Name G21,1),1_-ZZ _Zall License Phone <br />} TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 Q, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Asa_ SEWER LINES `-f 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 Cable Tool Dia, of Well Excavation 12 a <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 ,E.k�� .._ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: TTS de j <br /> PLW INSTALLATION: Contractor <br /> Type of Pump ze H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR:. / / State Work Done <br /> {DES•TRUCTION OF WELL: Well -Diameter Approximate Depth 4_0 <br /> Describe Material and Procedure <br /> i <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 notify them before putting the .well in .use. The above <br /> information is true to the best of y no ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G G D A INAL 5WCT <br /> SIGNED TITLE 'ni <br /> (DMW PLOT PLAN ON REVERSE SIDE) il <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� DATE f� <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ag <br /> P S GROU INSPEC ON <br /> TPHA;SE IFI AL INSPECT <br /> nX <br /> INSPECTION BY }, DATE -7,77"7`7 INSPECTION BDATEp 7= <br /> n�. .� .ver'"��,✓. fr <br />