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/ <br /> FOF�tOFFSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ICE USE: 1/ <br /> 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone:F" .(209) 466'-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> ccJ <br /> , <br /> THIS PERMIT EXPIRES 1 :XEAR FROM DATE ISSUED Date. Iasuedi'rJ <br /> (Complete In Triplicate).,.,,,' E ` _ <br /> Application is hereby made to the San Joaquin,.Local, Health District-:for. a:!;per'mit toEconstruct:: <br /> and/or install the work herein described. This application:jis rude,'in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of,.nhe: San•Joaq:uin=-.Local.-Health. District'. <br /> JOB ADDRESS/LOCATION <br /> © 6 <br /> We <br /> CENSUS TRACT i •; ; ' <br /> Owner's Name C�e lb's' �<e jC <br /> •Phone <br /> Address `City'" <br /> Contractor's Name �3c�c car License <br /> X07 "Phone:' -e6�6 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/_ RECONDITION '/_ DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /-7 ..PUMP REPLACEMENT <br /> Other <br /> ii <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD _ CESSPOOL/.SEEPAGE PTT OAR <br /> PROPERTY LINE/9-"PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _X Domestic/private Drilled Dia: of Well. -C& �r <br /> Domestic/public Driven Gauge of Casing f <br /> Irrigation Gravel: Pack Depth of Grout Seal �4" � <br /> w Cathodic Protection Rotary --.� <br /> Disposal TYPe of <br /> Dis - 1 <br /> p Other ... Other .Information <br /> Geophysical.~ SurfaceSeal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: I� / / State Work Done <br /> 4 <br /> PUNS .REPAIR: /_7 State Work Done <br /> ES;TRUCTION OF WELL. Well Diameter +Approximate Depth <br /> Describe Material and Procedure- <br /> 7 <br /> rocedure --------r- <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.Realth District a <br /> WELL DRILLERS REP of the well and notify them before Putting-the.-well in.use.. The above <br /> information i rue 'to the.best.of- my.knowledge and belief.- I WILL'CALL FOR A GROUT INSPECTION <br /> PRIOR TO ECTIO <br /> TITLE <br /> KMALW PLOT PLAN ON REVERSE SIDE <br /> Y FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY -� DATE <br /> ADDITIONAL COMMENTS: ,..,,_,.. <br /> PHASE I GROUT INSPECTION PHASE .1 I FINAL INSPECTION <br /> INSPECTION BY G✓ DATE d - /`> 7� INSPECTION BY(ir/ DATE <br /> E g 1426 . <br /> Rev. 1'7 4 <br /> _ 1 7G 7M <br />