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SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED <br /> F fi OFFICE USE: �`� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> or PLICATION 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 instal:r 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 District. <br /> JOB ADDRESS/LOCATIONS-� CENSUS TRACT <br /> Owner's Name __ /�5 Awe o l?o Phone .4 la b 71-K <br /> Addressy 'L .i� LI City5- <br /> Contractor's Name 1pzrr /kA License !�7,6yt " _one 14� <br /> TYPE OF WORK (Check): NEW WELL /d7, 11 DEEPEN J 7 RECONDITION f_7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/7 PUMP REPLACEMENT /7 <br /> Other /`// <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC- POIJESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> I ustrial %'OF-WELL <br /> Tool Dia. of Well Excavation (� <br /> EEDomestic/private Drilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informat own <br /> Geophysical Surface Seal Installed By:27 raC <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> .EM .REPAIR: /7 State Work Done <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 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-well71n.use.., The above <br /> information is true to the-best of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECT <br /> PRIOR TOG U ING FINAL IN ECTION. <br /> SIGNED TITLE <br /> DRAW PLOT P , ON REVERSE SIDE <br /> F D MENT USE LY <br /> PHASE I <br /> APPLICATION ACCEPFFA1CI DATE <br /> ADDITIONAL CO <br /> P INSPECTION PHAM1117TEMINSPICTION <br /> INSPECTION BY 11 rl, DATE - INSPECTION BY DATE ,b` <br /> E H 1426 L; -74 <br />