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' '_ SAN JOAQUIN LOCAL HEALTH DISTRICT � 5 <br /> y FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 <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 Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 3<La sS ZX C) e CENSUS TRACT ' <br /> Owner's Name W, Phone el'7 <br /> Address A m e City ZSC/qxoz!! <br /> a 7� pp <br />' Contractor's Name � License �� hone o.R�7 <br />'. TYPE OF WORK (Check) : NEW WELL /, / DEEPEN %/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP�:INSTAL.LATION X PUMP REPAIR / / PUMP REPLACEMENT /_7Other / / e '04c� G� l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT.PRIVY <br /> SEWAGE -DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE - PRT-LATE DOMESTIC 4 ZT.L PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL -CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 'Tobly _Dia. ofWell' Excavation <br /> Domestic/private Drilled-' Iiia.of Well Casing <br /> Domestic/public Driveii_.._' e Gauge-of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Cathodic Protection Rotaxy-ti Type of Grout l� <br /> Disposal Other Other Information <br /> Geophysical , Y Surface Seal Installed By <br /> I PUMP INSTALLATION: Contractor °T,D., �- <br /> Ty� , of Pump H.P. <br /> . <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP .REPAIR: _/ / State Work Done T <br /> DESTRUCTION OF WELL: Well'`+,Diameter Approximate Depth <br /> Desc'kibe Material and Procedure { .. <br /> k' I hereby agree to comply witW all laws and regulations of the San Joaquin Local Health District <br /> and the State of California `pdrtaining. l_ <br /> . to or. reguating 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-sand "' tify,;them;-before putting. the well 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 GRO NG AND A NAL INSPCTIUN: <br /> SIGNED <br /> (DRAW PLOT PLAN ON- REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY e�,FDATE 1 7-/r�? 7 <br /> ADDITIONAL COMMENTS: ZZ ` <br /> PHASE II GOWIWSPECTION. PIIASEIMIFINW INSPECTION <br /> INSPECTION BY V DATE INSPECTION BW <br /> DATE <br /> om 1t <br />