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SAN JOAQUIN .LOCAL -HEALTH DISTRICT <br /> 0—R OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . '(209)' 466.-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE-ISSUED Date Issued -7ti <br /> (Complete In. Triplicate). <br /> Application is hereby made :to the San Joaquin Local Health' Dist-ricilor a. permit.,to construct <br /> rind/or install the work herein described. This Applications is ade 'In' compliance With. San Joaquin. <br /> County Ordinance No. 1662 and the Rules and Regulations of the lan Joaquin Local Health District:. <br /> JOB ADDRESS/.LOCATION StY, 75 A.,' - - _-- r CENSUS TRACT <br /> Owner's Name , '1�. �:.CPfL - ---- _ Phone . g 7_ <br /> Addressl :. r- �� City-, c. <br /> Contractor's Naas. License # 7q C710 Phone '-�2 <br /> TYPE OF WORK (Check); ~uNEW WELL /7 DEEPEN ,/7 RECONDITION /? DESTRUCTION r T , <br /> PUMP INSTALLATION/ / PUMP REPAIR'o PUMP REPLACEMENT /7 <br /> Other /7 <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-We11J'Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/piiblic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal"-- Otherm Other Information: <br /> Geophysical Surface Seal Installed 'g <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> A / FState Work Done Pa <br /> 'PUMP :REPAIR•. <br /> DESTRUCTION OF WELL: Well Diameter 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 anew 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 ln.use.... The above <br /> information is true to-the•best ,of. my.knowledge and belief. I WILL CALL FOA A ,GROUT INSPECTIOIJ <br /> PRIOR TO GROUTING -AND 6 FIN INSPECTION657, <br /> . <br /> SIGNEDTITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I 3 <br /> A?rLICATION' ACCEPTED�nY 4 `; ',�'/! DATE <br /> f ADDITIONAL COMMENTS: 02 <br /> PHASE II!G UT INSPECTION P b <br /> INSPECTI <br /> INSPECTION BY DATE.4 INSPECTION B DATE <br />